Candida Catheters

Candida species are the most common opportunistic fungal pathogens encountered in hospitals, ranking as the third to fourth most common cause of nosocomial bloodstream infections in United States Hospitals.18 The incidence of nosocomial candidiasis has increased steadily since the early 1980s, with the widespread use of central venous catheters, broad-spectrum antimicrobials, and other advancements in the supportive care... 

Candida albicans, C. tropicalis, C parapsilosis and resolution of signs and symptoms of infection Remove existing central venous catheters when feasible, plus Amphotericin B IV 0.6 mg/k day or Fluconazole IV/po 6 mg/kg/day or An echinocandin or Amphotericin B IV 0.7 mg/kg/day plus fluconazole IV/po 800 mg/day Patients intolerant or refractory to other therapf Amphotericin B lipid complex IV 5 m k day Liposomal amphotericin B IV 3-5 mg/kg/day Amphotericin B colloid dispersion IV 2-6 mg/k day (continued)... 

Routine use of in-line filters with TNA solutions is controversial. A 1.2-micrometer filter can be used to prevent catheter occlusion caused by precipitates or lipid aggregates, and to remove Candida albicans. 

Camacho A, Gasparetto A, Svidzinski IE. (2007) The effect of chlorhexidine and gentian violet on the adherence of Candida spp. to urinary catheters. Mycopathologia 165 261-266. 

Nosocomial UTI is the most common infection in hospitals and nursing homes and 80% is associated with the use of urethral catheters. An incidence of bacteriuria of 3-10%/day makes the duration of catheterization the most important risk factor for bacteriuria. Asymptomatic bacteriuria should not be treated. However, up to 30% of patients with catheter-associated bacteriuria will develop fevers or other symptoms of UTI. In long term catheterization Providencia stmrtii and Candida species are the most common responsible organisms. Exchange of the catheter under therapy is advised in chronic cases. 

In a rat model of neonatal sepsis, recombinant HL or talactoferrin was shown to improve survival (Venkatesh et al., 2007). In ex vivo studies, HL increased synergy of commonly used antibiotics against coagulase-negative staphylococcus and Candida (Venkatesh and Rong, 2008) and reduced biofilm of infected catheters (Venkatesh et al., 2009). 

Candida albicans UTI is rarely found in patients within the community setting but is common in hospital patients with risk factors such as indwelling catheters, immunosuppression, diabetes mellitus and those on antibiotic treatment. 

The urinary pathogens in complicated or nosocomial infections may include E colt, which accounts for less than 50% of these infections, Proteus spp., Klebsiella pneumoniae, Enterobacter spp.. Pseudomonas aeruginosa, staphylococci, and enterococci. Candida spp. have become common causes of urinary infection in the critically ill and chronically catheterized patient. The majority of UTIs are caused by a single organism however, in patients vrith stones, indwelling urinary catheters, or chronic renal abscesses, multiple organisms may be isolated. 

Coagulase-negative staphylococci, such as Staphylococcus epidermidis, are the most common causes of catheter-related infections due to their ability to adhere to prosthetic material. Staphylococcus aureus, aerobic gramnegative bacilli, and Candida albicans are also common causes of catheter-related infections. Depending on local susceptibility patterns, methicillin-resistant S. aureus (MRSA) may represent up to 20% of all isolates. In contrast, upward of 80% of S. epidermidis are methicillin-resistant (MRSE). 

Initial therapy of candidal cystitis should focus on removal of urinary catheters whenever possible. Changing the catheter will eliminate candiduria in only 20% of patients, whereas discontinuation will eradicate Candida in 40% of patients. Asymptomatic candiduria rarely requires therapy. Therapy should be used in symptomatic patients and in neutropenic patients, as well as in patients with renal allografts and those who will undergo urologic manipulation, because of the risk of dissemination. ... 

PN solutions should be administered with an infusion pump to ensure consistent and controlled delivery of the solution. The intravenous administration line may include an in-line filter at a point prior to connection to the catheter. A 0.22-micron filter is recommended for use with CAA-dextrose solutions to remove particulate matter, air, and any microorganisms that may be present in the solution from prior manipulations of the admixture or the administration line. Because the average size of IVLE particles is approximately 0.5 micron, IVLEs administered separately from the CAA-dextrose solution must be piggybacked into the PN line at a site beyond the in-line fllter. Routine use of in-line filters (>0.22 micron) with TNA solutions is controversial. However, the FDA recommends use of a 1.2-micron filter, which may be effective in preventing catheter occlusion due to precipitates or lipid aggregates. This filter size is also reported to remove Candida albicans. 

Central catheters have been shown to be the most important risk factor in nosocomial Candida infections, which rival in seriousness any underlying disease. Catheters inserted in the subclavian or internal jugular vein have an infection rate of 3-5%—in some hospitals, 7-10%. Percutaneous inserted, noncuffed venous catheters used in hemodialysis are associated with the highest infection rate, 10%. 

An increasing proportion of inhavascular device-related infections are being caused by Candida spp. and the management of these infections can be challenging. Candida infections account for ca. 10% of the whole number of intravascular catheter-associated infections. Usually the management of these infections requires the device removal. 

Unfortunately, MR-coated intravascular catheters do not possess antimicrobial activity against strains of P. aeruginosa causing ca. 5% of CR-BSIs and Candida spp. contributing up to 12% of CR-BSls. " ... 

One infant died of Candida Sepsis on the 5th day of infusion no other catheter complications were encountered. Three other infants died from causes unrelated to the intravenous alimentation. 

The incidence of Candidiasis reported in this series is disturbing because of the recent association of Candidiasis with parenteral nutrition, by Ashcraft and Leape (5). The work of MacMillan, Law and Holder, however, documents the increasing problem of Candida in the burned child (6). Because of the number of variables involved, it is difficult in this series to assess the relationship between Candidiasis and central venous nutritional supplementation. The clinician caring for this type of patient, however, should be aware of this etiologic possibility when sepsis presents and treat when present by removing catheters and giving Amphotericin B. 

The observation that the serum inhibition of Candida albicans seen in normal patients (38) is lost in patients with Candida septicemia (12) raises interesting possibilities. In contradistinction to this we have found that patients can develop positive precipitin tests from Candida (47) without clinical evidence of can-didemia (blood culture negative, no fever)(16). These patients are receiving the "amphotericin flush" (15) (see below), and this implies that catheter-related candidemia may be dependent on repetitive inoculation to produce clinical candidemia. Finally, there is... 

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