Candidemia Following Ureteric Stent Placement in a Patient With Type 2 Diabetes Treated With Canagliflozin

Abstract

A 38-year-old female patient with well-controlled type 2 diabetes mellitus treated with canagliflozin underwent ureteral stent placement for obstructive renal calculi. Ten days following ureteroscopy and ureteral stenting, she developed fevers and blood cultures grew Candida glabrata (C. glabrata). The patient was successfully treated with an extended course of broad-spectrum antibiotics and antifungal agents. The clinical presentation of candidemia is indistinguishable from bacteremia resulting in delay in diagnosis and treatment. Candiduria is commonly seen in patients with type 2 diabetes, however it rarely leads to candidemia in an otherwise healthy person following a relatively simple urologic procedure. Sodium-glucose co-transporter 2 (SGLT-2) inhibitors act by its glycosuric effect and further increases the risk of genitourinary candida infection. Urologic procedures may lead to bloodstream entry of the genitourinary fungal organisms and result in life-threatening fungemia. Our case emphasizes the importance of awareness of the increased risk of potentially life threatening fungemia in patients using SGLT-2 inhibitors to avoid delay in diagnosis and treatment.

Risk factors for candidaemia: A prospective multi‐centre case‐control study

“…Candidaemia after ureteric instrumentation may in part be related to the formation of a biofilm on stents 39–41 . There are also reports in association with new agents for treatment of diabetes that cause marked glycosuria 42 . The urinary tract is being recognised as an increasingly important source of candidaemia and prompt removal of IDC when possible is key.…”

Uncommon Complications of Cystoscopy: Presentations of Concurrent Perirenal Hematoma and Candida albicans Sepsis

“…Devices such as stents and catheters have been known to facilitate biofilm formation with Candida spp., and the degree of biofilm formation is associated with enhanced virulence [ 13 ]. Additionally, from a previously conducted retrospective study, researchers identified “underlying risk factors like urinary tract abnormalities (88%), use of antibiotics within 1 week (85%), underlying malignancies (73%), urinary tract obstruction (73%), and prior urological procedure within 2 weeks (73%)” may increase susceptibility to candidemia from a urinary source [ 12 , 14 ]. Our patient not only underwent urological procedures but also urinary tract obstruction with his initial diagnosis of nephrolithiasis and was empirically treated with ceftriaxone for potential urinary tract infection at admission as well.…”

“…Our patient not only underwent urological procedures but also urinary tract obstruction with his initial diagnosis of nephrolithiasis and was empirically treated with ceftriaxone for potential urinary tract infection at admission as well. He was also a diabetic patient, despite having well-controlled blood glucose levels, which naturally predisposes to candiduria and thus candidemia [ 14 ].…”

“…Although most candidal colonization is asymptomatic and does not require treatment, the Infectious Diseases Society of America (IDSA) recommends that in non-neutropenic patients, echinocandins, such as caspofungin, are recommended as initial therapy (strong recommendation, high-quality evidence) with IV or oral fluconazole as an accepted alternative as initial therapy in patients “who are not critically ill and who are considered unlikely to have a fluconazole-resistant Candida species,” the latter of which was chosen as a treatment for our patient [ 14 , 15 ].…”