Complications of Candidemia in ICU Patients: Endophthalmitis, Osteomyelitis, Endocarditis

Abstract

Bloodstream infection with Candida species is not uncommon in the intensive care unit setting and has the potential to distribute organisms to many different organ systems causing secondary infections, such as endophthalmitis, osteomyelitis, and endocarditis. In some patients, these types of infections become manifested shortly after the episode of candidemia. In others, especially vertebral osteomyelitis, weeks pass before the diagnosis is entertained. Endophthalmitis should be sought by a retinal examination in all patients early after an episode of candidemia. Both osteomyelitis and endocarditis are less common complications of candidemia than endophthalmitis. In patients who manifest symptoms or signs suggesting these infections, magnetic resonance imaging and transesophageal echocardiography, respectively, are extremely helpful diagnostic tests. Newer approaches to the treatment of these infections allow the use of better tolerated, safer antifungal agents. Endophthalmitis is often treated with fluconazole or voriconazole, and the echinocandins are increasingly used, instead of amphotericin B, as initial therapy for osteomyelitis and endocarditis before step-down therapy to oral azole agents.

COVID-19: The Role of the Ophthalmologist in ICU

“…Endogenous endophthalmitis remains a risk for COVID-19 patients due to intravascular catheters, parenteral nutrition, dialysis and the use of broad-spectrum antibiotics. 7 Candida albicans and bacterium like Pseudomonas impose the biggest risk to endogenous endophthalmitis. 7 ICU staff may find it difficult to recognise this in sedated patients unless there is a notable hypopyon; thus, a dilated fundal examination will be required once there are positive blood cultures and the patient will need to be initiated on systemic antifungals or antibacterial.…”

“…7 Candida albicans and bacterium like Pseudomonas impose the biggest risk to endogenous endophthalmitis. 7 ICU staff may find it difficult to recognise this in sedated patients unless there is a notable hypopyon; thus, a dilated fundal examination will be required once there are positive blood cultures and the patient will need to be initiated on systemic antifungals or antibacterial. Moreover, chorioretinal lesions with vitreous activity may warrant intravitreal antifungal or antibacterial treatment in accordance to local microbiology protocol.…”

Antifungal Activity of the Natural Coumarin Scopoletin Against Planktonic Cells and Biofilms From a Multidrug-Resistant Candida tropicalis Strain

“…Invasive fungal infections produced by Candida spp. persist as the primary hospital-acquired bloodstream infections and are associated with high morbidity and mortality, especially in intensive care units (Kauffman, 2015;McCarthy and Walsh, 2017;Butts et al, 2019). While Candida albicans remains as the most frequent fungal species isolated from candidemic patients, other Candida species are often identified in clinical isolates (Reviewed in Guinea, 2014).…”

Candida spp. infective endocarditis: Characteristics and outcomes of twenty patients with a focus on injection drug use as a predisposing risk factor

“…Endocarditis appears to have the highest mortality rate of the complicating infections that can stem from candidaemia 14 . CIE can also cause many complications including septic emboli, heart failure and heart block 6,9,14 . These complications were also observed in our cohort, with 16 (80%) of the patients presenting with septic emboli, and 11 (55%) of them requiring ICU admission, emphasising the role of early identification and treatment in improving outcomes 3,4 …”

“…Endocarditis appears to have the highest mortality rate of the complicating infections that can stem from candidaemia 14 . CIE can also cause many complications including septic emboli, heart failure and heart block 6,9,14 .…”