What is the management of yeast-positive bacteremia associated with a Hemodialysis (HD) catheter?

Management of Yeast-Positive Bacteremia in Hemodialysis Catheter Patients

For hemodialysis catheter-related candidemia, the infected catheter must always be removed and systemic antifungal therapy administered for 14 days after the last positive blood culture. 1

Immediate Catheter Management

• Remove the hemodialysis catheter immediately when blood cultures are positive for Candida species 1
• Insert a temporary (nontunneled) catheter at a different anatomical site 1
• If absolutely no alternative sites are available, exchange the infected catheter over a guidewire as a last resort 1
• Place a new long-term hemodialysis catheter only after obtaining negative blood cultures 1

Antifungal Therapy Selection

For hemodynamically unstable patients or those with prior fluconazole exposure:

• Use amphotericin B or an echinocandin (caspofungin, micafungin, or anidulafungin) 1

For hemodynamically stable patients without recent fluconazole therapy:

• Fluconazole 400 mg daily is appropriate for fluconazole-susceptible organisms 1

For Candida krusei infections:

• Must use amphotericin B or an echinocandin, as C. krusei is intrinsically fluconazole-resistant 1

For Candida glabrata with decreased azole susceptibility:

• Echinocandins are preferred (caspofungin 70 mg IV loading dose then 50 mg daily; micafungin 100 mg IV daily; or anidulafungin 200 mg IV loading dose then 100 mg daily) 1

Duration of Antifungal Treatment

• Treat for 14 days after the last positive blood culture result and resolution of signs and symptoms of infection 1
• Extend to 4-6 weeks if persistent fungemia continues >72 hours after catheter removal, or if endocarditis or suppurative thrombophlebitis is present 1
• Treat for 6-8 weeks if osteomyelitis develops 1

Critical Monitoring and Follow-up

• Obtain surveillance blood cultures 1 week after completing antifungal therapy if the catheter was retained (though retention is not recommended for Candida) 1
• If follow-up cultures are positive, remove the catheter and place a new long-term dialysis catheter only after obtaining negative blood cultures 1

Important Caveats

Catheter salvage is NOT recommended for fungemia:

• Salvage rates with systemic antifungal therapy and antibiotic lock therapy for Candida species are only approximately 30% 1
• Catheter retention worsens outcomes in candidemia based on multiple prospective studies 1
• The infected catheter should be removed in all cases of documented catheter-related fungemia involving tunneled catheters 1

Assess for complications:

• Evaluate for endocarditis, particularly if bacteremia/fungemia persists >72 hours after catheter removal 1
• Consider transesophageal echocardiography in patients without contraindications to identify complicating endocarditis 1
• Monitor for metastatic infections including osteomyelitis and septic arthritis 1