What is the treatment for Catheter-Related Bloodstream Infection (CRBSI) due to Candida?

Treatment of Candida Catheter-Related Bloodstream Infection (CRBSI)

Remove the catheter immediately and initiate systemic antifungal therapy in all cases of Candida CRBSI, as catheter retention consistently worsens outcomes and increases mortality. 1

Catheter Management

Catheter removal is mandatory for Candida CRBSI and represents the most critical intervention for survival. 1

• For short-term catheters: Remove immediately and send the catheter tip for culture. 1

• For long-term catheters or implanted ports: Remove the device promptly, as all six prospective studies demonstrate that catheter retention worsens outcomes in candidemia. 1

• For patients with extremely limited venous access: Exchange the catheter over a guidewire and perform catheter cultures as a temporary measure only. 1 If the catheter tip grows the same Candida species as blood cultures, the catheter must be removed. 1

• Pediatric considerations: While vascular access difficulties in children sometimes necessitate catheter retention attempts, fungal infections require significantly longer time to clear without catheter removal, and mortality is higher when catheters are retained. 1 Treatment of catheter-associated fungemia without catheter removal has a low success rate and is associated with higher mortality. 1

Systemic Antifungal Therapy

Initiate antifungal therapy immediately for all Candida CRBSI cases, even if symptoms resolve after catheter removal. 1

For Azole-Susceptible Species (C. albicans and most isolates)

• Fluconazole 400 mg daily (6 mg/kg for pediatrics) for 14 days after the first negative blood culture. 1

For Azole-Resistant or Reduced-Susceptibility Species (C. glabrata, C. krusei)

First-line therapy should be an echinocandin or lipid formulation of amphotericin B. 1, 2

• Echinocandins (preferred): 1

  • Caspofungin: 70 mg IV loading dose, then 50 mg daily IV 1
  • Micafungin: 100 mg daily IV 1
  • Anidulafungin: 200 mg IV loading dose, then 100 mg daily IV 1

• Lipid formulations of amphotericin B (alternative): 3-5 mg/kg daily IV 1

• Conventional amphotericin B: Effective but associated with more adverse effects; reserve for situations where other agents are unavailable. 1

Species-Specific Considerations

• C. krusei: Has intrinsic fluconazole resistance; use echinocandins or amphotericin B formulations only. 2

• C. parapsilosis: May have higher MIC values to echinocandins; fluconazole remains effective if susceptible. 1

• C. glabrata: Often has reduced azole susceptibility; echinocandins or amphotericin B preferred. 1

Duration of Therapy

Treat for 14 days after the first negative blood culture result and catheter removal. 1

• Obtain follow-up blood cultures 48-72 hours after initiating therapy to document clearance. 1

• If persistent candidemia occurs beyond 72 hours of appropriate therapy, evaluate for complications including endocarditis, endophthalmitis, suppurative thrombophlebitis, or metastatic infection. 1

Monitoring for Complications

All patients with Candida CRBSI require evaluation for metastatic complications, particularly endophthalmitis. 3

• Ophthalmologic examination: Perform dilated fundoscopic exam within 1 week of diagnosis to detect endophthalmitis or chorioretinitis. 3

• Evaluate for endocarditis: Particularly in patients with prosthetic valves, prolonged candidemia, or persistent fever despite therapy. 1

• Assess for suppurative thrombophlebitis: Suspect in patients with persistent fungemia beyond 3 days of adequate therapy; confirm with imaging (CT or ultrasound). 1

• Check for other metastatic sites: Including liver, spleen, kidneys, and bones, especially if fever or symptoms persist. 3

Antibiotic Lock Therapy

Antifungal lock therapy is investigational and NOT recommended as standard practice for Candida CRBSI. 1

• Limited data suggest amphotericin B lock therapy may allow catheter salvage in select cases, but this approach has insufficient evidence for routine use. 1

• In pediatric patients with extremely limited venous access, some reports show high cure rates with antifungal lock therapy combined with systemic therapy, but this remains experimental and should only be attempted in exceptional circumstances with close monitoring. 1

• Echinocandins, lipid amphotericin formulations, and ethanol-based locks eradicate Candida biofilms in vitro, but clinical efficacy for catheter retention is unproven. 1

Critical Pitfalls to Avoid

• Never use fluconazole empirically before species identification and susceptibility testing, as C. krusei has intrinsic resistance and C. glabrata frequently has reduced susceptibility. 2

• Never delay catheter removal in an attempt to preserve venous access, as all prospective studies show catheter retention worsens outcomes. 1, 2

• Never assume symptom resolution after catheter removal means cure; systemic antifungal therapy is mandatory even if clinical manifestations resolve. 1

• Never use echinocandins alone for urinary tract candidiasis, as they do not achieve adequate urinary concentrations. 4

• Never stop therapy before 14 days after documented clearance, as premature discontinuation increases relapse risk. 1