Management of Yeast in Sputum: Anidulafungin (Eraxis) Not Indicated

Growth of Candida from respiratory secretions usually indicates colonization and rarely requires treatment with antifungal therapy. 1

Understanding Yeast in Respiratory Secretions

The isolation of Candida species from the respiratory tract is commonly encountered, especially among patients in ICU settings who are intubated or have chronic tracheostomies 1
This finding almost always reflects colonization of the airways and not infection 1
Candida pneumonia and lung abscess are very uncommon conditions 1

Multiple prospective and retrospective autopsy studies consistently demonstrate the poor predictive value of Candida growth from respiratory secretions, including bronchoalveolar lavage (BAL) fluid 1
In one prospective study, none of 77 patients who died in an ICU with clinical and radiologic evidence of pneumonia and positive Candida cultures from BAL or sputum demonstrated evidence of Candida pneumonia at autopsy 1
A firm diagnosis of Candida pneumonia requires histopathological evidence of invasive disease, not just positive cultures 1

Primary Candida pneumonia occurs rarely, usually after aspiration of oropharyngeal material 1
Pneumonia due to Candida species is generally limited to severely immunocompromised patients who develop infection following hematogenous spread to the lungs 1
In severely immunosuppressed patients, isolation of Candida from respiratory samples should trigger a search for evidence of invasive candidiasis elsewhere in the body 1
CT scan of the thorax typically shows multiple pulmonary nodules in cases of true Candida pneumonia 1

Eraxis (anidulafungin) is FDA-approved for candidemia and other forms of Candida infections (intra-abdominal abscess and peritonitis) in adults and pediatric patients (1 month of age and older), as well as esophageal candidiasis in adults 2
It has not been studied in sufficient numbers of neutropenic patients or in patients with endocarditis, osteomyelitis, and meningitis due to Candida 2
The dosage for CNS and eye Candida dissemination has not been established 2
Anidulafungin is not indicated for treatment of colonization of the respiratory tract with Candida 1, 2

Recent observations suggest that colonization of the airway with Candida species is associated with the development of bacterial colonization and pneumonia 1
Candida airway colonization has been associated with worse clinical outcomes and higher mortality in some studies 1
However, it is not clear if Candida airway colonization has a causal relationship to poorer outcomes or is simply a marker of disease severity 1

A decision to initiate antifungal therapy should not be made on the basis of respiratory tract culture results alone 1
Because of the rarity of Candida pneumonia and the extremely common finding of Candida in respiratory secretions, treatment is not recommended for isolated positive respiratory cultures 1
If there are concerns about invasive candidiasis, look for evidence of infection at other sites 1

If a patient is severely immunocompromised with positive respiratory Candida cultures AND has radiographic evidence of pulmonary nodules, further investigation for invasive candidiasis is warranted 1
In patients with suspected invasive candidiasis elsewhere in the body, echinocandins (including anidulafungin) are recommended as first-line therapy in moderately to severely ill patients 3
For confirmed invasive candidiasis requiring anidulafungin, the recommended dose is 200 mg loading dose on Day 1, followed by 100 mg once daily maintenance dose for at least 14 days after the last positive culture 2