Unexpected candidemia complicating ureteroscopy and urinary stenting

Abstract

Two elderly patients with obstructive renal calculi who developed Candida albicans bloodstream infection within 12 h following ureteroscopy and ureteral stenting are described. Both patients were treated with prolonged courses of broad-spectrum antibiotics and were found to have urine cultures positive for Candida albicans prior to the urologic procedures. One patient also developed bilateral candidal endophthalmitis. The clinical presentation was indistinguishable from bacteremia complicating manipulation of the urinary tract. The patients were successfully treated with systemic antifungal therapy. Candiduria may present a risk for dissemination during invasive, relatively simple urologic procedures.

Epidemiology and prognosis of candidaemia in elderly patients

“…This lack of treatment has been related to patient death or discharge prior to the notification of the candidaemia and to the futility of treatment in patients in final stages of life . The previously mentioned lower frequency of HIV infection, haematological cancer, ICU admission, central venous catheterisation, parenteral nutrition or mechanical ventilation could have effectively reduced the clinical suspicion of candidaemia and therefore led to the incorrect interpretation of blood cultures results in these patients . Low expectation of candidaemia may consequently interfere with adequate patient management as has previously been observed and should therefore be a target for improvement over the next few years.…”

The pathophysiology and treatment of Candida sepsis

“…For these reasons, disruption of normal flora with broad-spectrum antibiotics increases the risk of developing disseminated candidiasis [15]. Disruption of normal skin barriers, for example by burn injury [15] or percutaneous catheter placement [2], is also a risk factor for development of invasive candidiasis, as is disruption of mucosal barriers, for example by abdominal surgery [15], instrumentation [16], induction of mucositis [17], or mucosal atrophy from radiation or parenteral nutrition. Percutaneous catheters provide a dual benefit to the organism by providing a plastic surface to which Candida adheres avidly and by bypassing the structural barrier of keratinized skin.…”

To treat or not to treat – critically ill patients with candiduria

“…In one trial, none of 316 asymptomatic or minimally symptomatic patients with candiduria developed candidaemia, 24 and in another study 1 only seven (1.3%) of 530 patients with candiduria and a follow‐up for 12 weeks developed candidaemia. However, candidaemia can follow candiduria in the presence of obstruction 72 . As a result, prophylactic antifungal agents should be administered to patients undergoing urinary tract procedures to relieve obstruction 9 .…”

“…However, candidaemia can follow candiduria in the presence of obstruction. 72 As a result, prophylactic antifungal agents should be administered to patients undergoing urinary tract procedures to relieve obstruction. 9 As a rule, for patients with sepsis who have candiduria, it is mandatory to obtain blood cultures and to exclude urinary obstruction.…”