Candida Empyema Thoracis at Two Academic Medical Centers: New Insights Into Treatment and Outcomes

Abstract

Background Candida empyema thoracis (pleural empyema) is an uncommon manifestation of invasive candidiasis, for which optimal treatment is unknown. Methods This is a retrospective study of patients with Candida empyema at 2 academic medical centers from September 2006 through December 2015. Results We identified 81 patients with Candida empyema (median age, 62 years; 68% men). Sixty-five percent of patients underwent surgery or an invasive intervention of the thorax or abdomen within the preceding 90 days. Candida empyema originated from intrathoracic (51%) or intra-abdominal sources (20%), spontaneous esophageal rupture (12%), pleural space manipulation (9%), and pneumonia (6%). Eighty-four percent and 41% of patients were intensive care unit residents and in septic shock, respectively, within 3 days of diagnosis. Causative species were Candida albicans (65%), Candida glabrata (26%), Candida parapsilosis (11%), Candida tropicalis (4%), Candida krusei (2%), and Candida dubliniensis (1%). Bacteria were recovered from empyemas in 51% of patients. Concurrent candidemia was diagnosed in only 2% of patients. Management included pleural drainage and antifungal treatment in 98% and 85% of patients, respectively. Mortality at 100 days was 27%, and it was highest for cases stemming from esophageal rupture (67%). Spontaneous esophageal rupture and echinocandin rather than fluconazole treatment were independent risk factors for death at 100 days (P = .003 and .04, respectively); receipt of antifungal therapy was an independent predictor of survival (P = .046). Conclusions Candida empyema mortality rates were lower than reported previously. Optimal management included pleural drainage and fluconazole treatment. Superiority of fluconazole over echinocandins against Candida empyema needs to be confirmed in future studies.

Candida glabrata Empyema Thoracis—A Post-COVID-19 Complication

“…The identified risk factors for the development of Candida empyemas include elderly age, underlying comorbidities (such as diabetes mellitus, chronic kidney disease, cirrhosis, and malignancies), septic shock, receipt of steroids or chemotherapy, prolonged antibiotic use, ICU stay, and intra-abdominal diseases (such as esophageal rupture, complicated surgery, pancreatitis, etc.) [2,[7][8][9]. The distribution of Candida species in large case series describing the entity of fungal empyemas has shown that a majority are secondary to C. albicans, while NAC are less common [2,7,8].…”

“…[2,[7][8][9]. The distribution of Candida species in large case series describing the entity of fungal empyemas has shown that a majority are secondary to C. albicans, while NAC are less common [2,7,8]. However, the ongoing shift in prevalence of NAC may alter the epidemiology of this condition in the future.…”

“…Invasive candidiasis, especially candidemia, has increasingly been recognized as a complication of COVID-19 and is associated with an estimated mortality of 19-40% overall, with as high as 70% in critically ill patients [1]. Candida empyemas are a rare but severe manifestation of invasive candidiasis with scarce data on their optimal management [2]. Additionally, the landscape of Candida infections continues to shift with a growing number of non-albicans Candida (NAC) cases being reported.…”

Risk factors for invasive aspergillosis in ICU patients with COVID-19: current insights and new key elements

“…The correlation between bacterial and viral superinfections and the development of CAPA in ICU COVID-19 patients has not been specifically investigated [ 19 , 26 , 34 ]. It is likely that the logistical difficulties associated with the pandemic spread have made the multi-resistant Gram-negative bacteria superinfections particularly frequent and severe [ 46 , 47 ]. To date, only one study [ 34 ] specifically addresses the issue of the possible correlation between previous broad-spectrum antibiotic therapy (notably carbapenems) and fungal superinfections.…”

Invasive Fungal Diseases in Hospitalized Patients with COVID-19 in Israel: A Multicenter Cohort Study

“…Candida empyema was associated with prolonged mechanical ventilation and pulmonary thromboembolism. A recent review of Candida empyema thoracis attributed most cases to thoracic surgery, pleural instrumentation, and esophageal rupture [ 28 ], whereas this disease is rare in mechanically ventilated patients without prior pleural manipulation. Our findings suggest that thoracic Candida empyema could occur in critically ill COVID-19 patients due to prolonged mechanical ventilation, lung parenchymal necrosis, barotrauma, and overt or occult bronchopleural fistula formation [ 29 , 30 ].…”