Candiduria in ICU : when and how to treat? Dr. Debashis Dhar Dept of Critical Care and Emergency Medicine Sir Ganga Ram Hospital

Candiduria in ICU : when and how to treat? Dr. Debashis Dhar Dept of Critical Care and Emergency Medicine Sir Ganga Ram Hospital

Introduction Nosocomial bacteriuria or candiduria develops in up to 25% of patients requiring a urinary catheter for > 7 days, with a daily risk of 5% Candiduria is common in ICU

CAUTI in ICU SGRH (2013-15) 2.55/1000 urinary catheter days 5% 6% incidence(%) 43% candida non albicans VRE Pseudomonas 45% Kledsiella others

29% had candiduria; 66% non albicans 80% catheterised 29% mortality in candiduria

Intensive Care Med (2003) 29:1069 1076 This was a prospective, cohort, observational and multicenter study.. In 389 patients (22%), Candida spp. in one or more urine samples were isolated In-hospital mortality was 48.8% in patients with candiduria compared to 36.6% in those without candiduria (P<0.001). Significant differences were also found for ICU mortality (38.% vs. 28.1%, P<0.001)

Clinical Infectious Diseases 2000;30:14 8 - Multicenter prospective trial ; 861 pts had candiduria - 60% female - Concomitant nonfungal infections were present in 85%, - - 90% had received antimicrobial agents - 83.2% had urinary tract drainage devices.

-491 (57%) received no antifungal therapy from the clinician - 19.8% patients died ; in 42% candiduria cleared Only 7 patients (1.3%) developed candidemia. Five of the 7 patients with candidemia died, but only 2 of the 5 deaths were attributed to candidal infection Candiduria was documented prior to candidemia in 6 patients and was persistent in 4.

Clinician Dilemma No reference standard exists for the diagnosis of UTIs due to Candida species No studies have unequivocally established the importance of pyuria or quantitative urine cultures for UTI due to Candida. In the presence of obstruction candida can lead to candidemia Clinical Infectious Diseases 2005;41:S371 6

Risk Factors CID 2011:52 (Suppl 6) d S433

Approach to Candiduria Candiduria signifies severity of the illness Forerunner of severe fungal infection In ICU all patients have the risk factors

Candiduria Asymptomatic Symptomatic Invasive Candidiasis Candidemia

Symptomatic candiduria -As majority candiduria are asymptomatic a proper further evaluation is needed -- repeat culture with new cthwter - microscopic evidence for yeasts or casts look for ascending infection by imaging / radiology CT scan of KUB region

Candidemia from a Urinary Tract Source: Microbiological Aspects and Clinical Significance B. S. P. Ang*, A. Telenti, B. King, J. M. Steckelberg, and W. R. Wilson 26 cases of candidemia with candiduria studied retrospectively 19 patients had urinary procedure before candidemia 5 patients(19%) died Patients with candiduria undergoing surgery should have antifungal prophylaxis

What Is the Treatment for Asymptomatic Candiduria? Recommendations Elimination of predisposing factors, such as indwelling bladder catheters, is recommended whenever feasible (strong recommendation; low-quality evidence). Treatment with antifungal agents is NOT recommended unless the patient belongs to a group at high risk for dissemination

High Risk Group neutropenic patients very low-birth-weight infants (<1500 g), and patients who will undergo urologic manipulation Post renal transplant

Candid Candiduria

Candiduria In ICU Should other sites of colonisation be ruled out? How to further work up? How to monitor? Role of antifungals?!?

ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, Sept. 2005, p. 3640 3645

ANNALS OF SURGERY Vol.220,No.6,751-758

-Weekly fungal surveillance from admission to discharge or death - 92 pts included after exclusion with mean SAPS of >40 Candida spp. colonization patterns (CI colonization index)

Only one patient with CI>0.5 developed invasive candidiasis Candiduria and CI has no significant correlation to mortality

Int.J.Curr.Microbiol.App.Sci (2015) 4(11): 470-486

The author reviewed all the studies in ICU with CI and their predictive value for invasive candidiasis High negative predictive value rather than definitive diagnosis CI of >0.5 is associated with increased IC

169 ICUs and 2047 patients 154 patients (7.5%) had antifungal therapy of which only 54 had IFI

Intensive Care Med (2005) 31:1514 1521 Critical Care Specialists tend to use antifungals more than the ID Clinical Condition Central Line Candidemia Critical Care Specialists 77% 50% Peritoneal fluid 22% 7% BAL candida 51% 5% ID specialist

Treatment of Candiduria Infect Dis Clin N Am 28 (2014) 61 74

Clinical Infectious Diseases 2000;30:19 24. Oral fluconazole was safe and effective for short-term eradication of candiduria, especially following catheter removal. Long-term eradication rates were disappointing and not associated with clinical benefit.

Conclusion Always rule out colonization by catheter removal and repeat culture In ICU rule out invasive candidiasis in presence of candiduria Depending upon individual cases if needed prophylactic antifungals may be considered in ICU

Thank You

20% of the patients had Candiduria http://dx.doi.org/10.1016/j.ajic.2015.03.013