Clinical characteristics and risk factors for complications of candidaemia in adults: Focus on endophthalmitis, endocarditis, and osteoarticular infections

[Endogenous Candida endophthalmitis]

Endogenous Candida endophthalmitis is a rare but vision-threatening disease. In most cases, endogenous endophthalmitis caused by Candida species has a better prognosis than endogenous endophthalmitis caused by other fungal species or bacteria but the prognosis still depends heavily on the time required for diagnosis and subsequent treatment as well as the initial visual acuity. Suggestions for treatment algorithms have already been made in the past but binding guidelines in ophthalmology only exist sporadically due to the rarity of the disease. This review discusses the current knowledge on endogenous Candida endophthalmitis and draws conclusions from the current study situation.

[Endogenous Candida endophthalmitis: diagnostics and treatment options based on case studies]

BACKGROUND

Endogenous Candida endophthalmitis is an emergency that can threaten vision and the eye as a whole organ but also the life of the patient due to its systemic cause.

MATERIAL AND METHOD

Retrospective case evaluation of the University Hospital for Ophthalmology Halle (Saale) and the Eye Clinic of the Ernst von Bergmann Hospital Potsdam from 2017-2022. (Age, gender, side involvement, underlying diseases, symptoms, preoperative and postoperative visual acuity, diagnostics, treatment and complications). The standardized procedures for endogenous Candida endophthalmitis are explained, the data are compared with the literature and treatment suggestions are presented.

RESULTS

8 patients with 14 eyes were treated for endogenous Candida endophthalmitis. Of the patients 2 were women and 6 were men. The overall average age was 70.25 years (53-82 years), 6 patients had bilateral eye involvement and 2 patients were affected on one side. All patients had several serious immunocompromising underlying diseases that were the cause of the candidemia. All patients underwent a pars plana vitrectomy (ppV) on the affected eyes except for one male patient who did not obtain permission for anesthesia. In addition to systemic treatment with antimycotics, voriconazole was routinely administered intravitreally during ppV. The patients received further intravitreal doses of voriconazole based on the findings. Vitreous body samples were taken from all patients during the ppV and detection of Candida albicans was possible in all cases. As part of the local perioperative treatment 1 patient received parabulbar administration of a triamcinolone depot in both eyes, 7 patients received a dexamethasone depot in 11 eyes and all 8 patients received findings-oriented local treatment with prednisolone acetate eye drops. visual acuity increased from preoperatively 1.2 logMar to 1.0 logMar. Postoperative retinal detachment did not occur and there were no serious perioperative complications. 2 patients died from one of the underlying diseases after 3 and 25 months, respectively.

CONCLUSION

Despite an increasing number of case series, there are still no uniform guidelines for ophthalmologists in Germany. There is agreement regarding systemic treatment and the intravitreal administration of antifungal agents. The role of ppV has not yet been clearly defined and the question of the adjuvant use of steroids (systemic and/or local) has also not been conclusively clarified.

Embolic stroke and misidentification candida species endocarditis: Case presentation and literature review

Fungal endocarditis is a rare but serious form of infective endocarditis associated with high morbidity and mortality. Among fungal pathogens, Candida species are the most frequently isolated and commonly found in individuals with predisposing factors, such as prosthetic heart valves. The clinical presentation of endocarditis is highly variable and nonspecific, often including symptoms and signs of embolization. In this paper, we present a case of fungal prosthetic valve endocarditis in which the initial presentation was an acute ischemic stroke. The initial misidentification of Candida famata was attributed to limitations in the presumptive methodology used through selective chromogenic culture identification. However, the surgical specimen underwent mass spectrometry, leading to the correct identification of Candida guilliermondii instead of Candida famata. Furthermore, we conducted a non-systematic narrative review of the literature on Candida endocarditis. Our findings underscore the importance of considering fungal endocarditis in the differential diagnosis of patients with possible extracardiac complications, particularly those with a history of heart valve replacement. Early diagnosis and a comprehensive treatment strategy tailored by species identification and antifungal susceptibility testing are crucial in improving patient outcomes.

Use of Optical Coherence Tomography and Optical Coherence Tomography Angiography in the Diagnosis and Follow-Up of Endogenous Candida Endophthalmitis: A Case Report

Background: Endogenous Candida endophthalmitis (ECE) is a rare but sight-threatening disease. Patients with ECE present with various clinical signs and symptoms, which can complicate the diagnosis. The aim of this report was to demonstrate the outcomes of treatment and to diagnose macular complications caused by intraocular inflammation. Case presentation: A 41-year-old woman with a history of acute intermittent porphyria presented with a progressive vision loss in her left eye. Left-eye OCT revealed findings consistent with a fungal etiology, which was confirmed by the culture of swabs collected from a central vein catheter. The outcomes of intravenous fluconazole treatment were not satisfactory, and the patient developed recurrent attacks of porphyria, suggesting a porphyrogenic effect of systemic antifungal therapy. Repeated intravitreal injections with amphotericin B led to a gradual regression of inflammatory lesions. However, follow-up examinations revealed active macular neovascularization (MNV) on both OCT and OCTA scans. The patient was administered intravitreal bevacizumab. At the 11th month of follow-up, OCT and OCTA scans showed significant inflammatory lesions regression with macula scarring, and no MNV activity was detected. Conclusions: This case highlights the importance of OCT and OCTA as valuable noninvasive imaging techniques for the identification of ECE, the monitoring of its clinical course, and the diagnosis of macular complications.

Fungal Endocarditis: Pathophysiology, Epidemiology, Clinical Presentation, Diagnosis, and Management

Fungal endocarditis accounts for 1% to 3% of all infective endocarditis cases, is associated with high morbidity and mortality (>70%), and presents numerous challenges during clinical care. Candida spp. are the most common causes of fungal endocarditis, implicated in over 50% of cases, followed by Aspergillus and Histoplasma spp. Important risk factors for fungal endocarditis include prosthetic valves, prior heart surgery, and injection drug use. The signs and symptoms of fungal endocarditis are nonspecific, and a high degree of clinical suspicion coupled with the judicious use of diagnostic tests is required for diagnosis. In addition to microbiological diagnostics (e.g., blood culture for Candida spp. or galactomannan testing and PCR for Aspergillus spp.), echocardiography remains critical for evaluation of potential infective endocarditis, although radionuclide imaging modalities such as 18F-fluorodeoxyglucose positron emission tomography/computed tomography are increasingly being used. A multimodal treatment approach is necessary: surgery is usually required and should be accompanied by long-term systemic antifungal therapy, such as echinocandin therapy for Candida endocarditis or voriconazole therapy for Aspergillus endocarditis.

Prevalence of Ocular Candidiasis and Candida Endophthalmitis in Patients With Candidemia: A Systematic Review and Meta-Analysis

BACKGROUND

Infectious diseases and ophthalmology professional societies have disagreed regarding ocular screening in patients with candidemia. We aimed to summarize the current evidence on the prevalence of ocular candidiasis (OC) and Candida endophthalmitis (CE) according to the standardized definitions.

METHODS

A literature search was conducted from the inception date through 16 October 2022 using PubMed, Embase, and SCOPUS. Pooled prevalence of ocular complications was derived from generalized linear mixed models (PROSPERO CRD42022326610).

RESULTS

A total of 70 and 35 studies were included in the meta-analysis for OC and concordant CE (chorioretinitis with vitreous involvement), respectively. This study represented 8599 patients with candidemia who underwent ophthalmologic examination. Pooled prevalences (95% CI) of OC, overall CE, concordant CE, and discordant CE were 10.7% (8.4-13.5%), 3.1% (2.1-4.5%), 1.8% (1.3-2.6%), and 7.4% (4.5-12%) of patients screened, respectively. Studies from Asian countries had significantly higher concordant CE prevalence (95% CI) of patients screened (3.6%; 2.9-4.6%) compared with studies from European countries (1.4%; .4-5%) and American countries (1.4%; .9-2.2%) (P <.01). Presence of total parenteral nutrition and Candida albicans was associated with CE, with pooled odds ratios (95% CI) of 6.92 (3.58-13.36) and 3.02 (1.67-5.46), respectively.

CONCLUSIONS

Prevalence of concordant CE overall and among Asian countries was 2 and 4 times higher than the prevalence previously reported by the American Academy of Ophthalmology (AAO) of <0.9%, respectively. There is an urgent need to study optimal screening protocols and to establish joint recommendations by the Infectious Diseases Society of America and AAO.

Risk factors for ophthalmologic involvement and ocular findings in patients diagnosed with fungemia in a high-complexity hospital in the city of Medellín, Colombia

PURPOSE

To describe the demographic clinical characteristics and to identify the risk factors of patients diagnosed with fungemia and secondary intraocular involvement.

METHODS

Retrospective cohort of 97 patients diagnosed with fungemia and with or without involvement of the posterior segment. Demographic, clinical and ophthalmological variables were identified to establish the risk of retinal seeding.

RESULTS

An incidence of ocular involvement of 22.68% was obtained and no clear risk factor was found for subsequent showings in patients with fungemia. A risk trend was only found in patients with diabetes with an OR: 2.85; CI 95%: (0.80-10.12) and history of HIV with an OR: 2.29 CI95%: (0.85-6.12).

CONCLUSIONS

In this first cohort carried out in Colombia according to our search, findings were obtained that agree with those of other authors worldwide, where there is no evidence of a decrease in incidence compared with older studies and the absence of risk factors for the compromise of the posterior pole in patients with fungemia.KEY MESSAGESSystematic fundus evaluation by an ophthalmologist in patients with candidaemia is a recommended practice based on low-quality evidence.The identification of real risk factors for retinal compromise in fungemia would allow us to be more selective with the population to be evaluated.Fungemia generally occurs in critically ill patients, where access and availability of ophthalmology evaluation are a resource that is not always available.

American Academy of Ophthalmology Recommendations on Screening for Endogenous Candida Endophthalmitis

The American Academy of Ophthalmology evaluated the practice of routine screening for intraocular infection from Candida septicemia. In the United States, ophthalmologists are consulted in the hospital to screen for intraocular infection routinely for patients with Candida bloodstream infections. This practice was established in the era before the use of systemic antifungal medication and the establishment of definitions of ocular disease with candidemia. A recent systematic review found a rate of less than 1% of routinely screened patients with endophthalmitis from Candida septicemia. Other studies found higher rates of endophthalmitis but had limitations in terms of inaccuracies in ocular disease classification, lack of vitreous biopsies, selection biases, and lack of longer-term visual outcomes. Some studies attributed ocular findings to Candida infections, rather than other comorbidities. Studies also have not demonstrated differences in medical management that are modified for eye disease treatment; therefore, therapy should be dictated by the underlying Candida infection, rather than be tailored on the basis of ocular findings. In summary, the Academy does not recommend a routine ophthalmologic consultation after laboratory findings of systemic Candida septicemia, which appears to be a low-value practice. An ophthalmologic consultation is a reasonable practice for a patient with signs or symptoms suggestive of ocular infection regardless of Candida septicemia.

Mind the gaps: challenges in the clinical management of invasive candidiasis in critically ill patients

PURPOSE OF REVIEW

Strict adherence to clinical practice guidelines is recognized to improve outcomes but the inconvenient truth is that only a small subset of what is done in medicine has been tested in appropriate, well designed studies. In this article, we aim to review controversial aspects of the clinical management of invasive candidiasis recommended by guidelines.

RECENT FINDINGS

Despite still being recommended by guidelines, we fail to identify a single randomized clinical trial documenting that the use of antifungal drugs in high-risk critically ill patients without microbiologic documentation of Candida infection decreases mortality. Regarding deep-seated Candida infections, most cohort studies of patients with candidemia found less than 5% of patients developed endophthalmitis and endocarditis. In this scenario, it is reasonable to reconsider routine universal screening of both complications in candidemic patients. Finally, a large number of studies have shown that critically ill patients usually have lower echinocandin exposure when compared with other populations. We need more data on the clinical relevance of this finding.

SUMMARY

We need robust studies to validate new strategies for the clinical management of candidemia in ICU, including: the use of fungal biomarkers in the early initiation or interruption of antifungal therapy in high-risk patients to replace the conventional empirical antifungal therapy driven by predictive rules; validation of targeted screening of eye infection and endocarditis with the aid of fungal biomarkers only in high-risk patients; we should clarify if higher doses of candins are necessary to treat invasive candidiasis in critically ill patients, especially in the case of intra-abdominal infections where drug penetration is suboptimal.