Gallbladder and biliary tract candidiasis

A Challenging Case of Biliary Obstruction in an 82-Year-Old Male With a History of Zollinger-Ellison Syndrome and Suspected Cholangiocarcinoma Secondary to Biliary Candidiasis

Biliary obstruction is a serious condition with various underlying causes, including malignancy, infection, and gallstones. Fungal biliary infections are rare, frequently misdiagnosed, and carry significant morbidity and mortality. Here, we present the case of an 82-year-old male with multiple comorbidities who developed sepsis secondary to cholangitis. Despite initial diagnostic challenges and the complexity of his biliary anatomy due to prior surgeries, a multidisciplinary approach identified biliary candidiasis as the underlying cause of cholangitis and sepsis. This case underscores the importance of considering fungal infections in the differential diagnosis of biliary obstruction, particularly in high-risk and immunosuppressed patients. Early recognition is essential to enable prompt treatment and improve patient outcomes.

An Acute Gangrenous Cholecystitis Caused by Candida auris: A Case From a Greek Hospital

Candida-related infections have increased dramatically in recent years, particularly in severely sick or immunocompromised individuals. Furthermore, the discovery of Candida auris in 2009 as a fungus resistant to numerous antifungal treatments has increased its significance. This microorganism is linked to high transmission rates among hospitalized patients, resulting in life-threatening infections and complications. This is a complete case study that explains the reasons and suitable therapy for this medical condition. Despite receiving adequate therapy, individuals with acute gangrenous cholecystitis typically have a poor prognosis. As a result, physicians must be aware of this illness and provide the best therapy as soon as possible. Here, we present a case of gangrenous cholecystitis caused by Candida auris in a 58-year-old woman.

The footprint of gut microbiota in gallbladder cancer: a mechanistic review

Gallbladder cancer (GBC) is the most common malignant tumor of the biliary system with the worst prognosis. Even after radical surgery, the majority of patients with GBC have difficulty achieving a clinical cure. The risk of tumor recurrence remains more than 65%, and the overall 5-year survival rate is less than 5%. The gut microbiota refers to a variety of microorganisms living in the human intestine, including bacteria, viruses and fungi, which profoundly affect the host state of general health, disease and even cancer. Over the past few decades, substantial evidence has supported that gut microbiota plays a critical role in promoting the progression of GBC. In this review, we summarize the functions, molecular mechanisms and recent advances of the intestinal microbiota in GBC. We focus on the driving role of bacteria in pivotal pathways, such as virulence factors, metabolites derived from intestinal bacteria, chronic inflammatory responses and ecological niche remodeling. Additionally, we emphasize the high level of correlation between viruses and fungi, especially EBV and Candida spp., with GBC. In general, this review not only provides a solid theoretical basis for the close relationship between gut microbiota and GBC but also highlights more potential research directions for further research in the future.

Insight into the mechanism of gallstone disease by proteomic and metaproteomic characterization of human bile

Introduction

Cholesterol gallstone disease is a prevalent condition that has a significant economic impact. However, the role of the bile microbiome in its development and the host's responses to it remain poorly understood.

Methods

In this study, we conducted a comprehensive analysis of microbial and human bile proteins in 40 individuals with either gallstone disease or gallbladder polyps. We employed a combined proteomic and metaproteomic approach, as well as meta-taxonomic analysis, functional pathway enrichment, and Western blot analyses.

Results

Our metaproteomic analysis, utilizing the lowest common ancestor algorithm, identified 158 microbial taxa in the bile samples. We discovered microbial taxa that may contribute to gallstone formation, including β-glucuronidase-producing bacteria such as Streptococcus, Staphylococcus, and Clostridium, as well as those involved in biofilm formation like Helicobacter, Cyanobacteria, Pseudomonas, Escherichia coli, and Clostridium. Furthermore, we identified 2,749 human proteins and 87 microbial proteins with a protein false discovery rate (FDR) of 1% and at least 2 distinct peptides. Among these proteins, we found microbial proteins crucial to biofilm formation, such as QDR3, ompA, ndk, pstS, nanA, pfIB, and dnaK. Notably, QDR3 showed a gradual upregulation from chronic to acute cholesterol gallstone disease when compared to polyp samples. Additionally, we discovered other microbial proteins that enhance bacterial virulence and gallstone formation by counteracting host oxidative stress, including sodB, katG, rbr, htrA, and ahpC. We also identified microbial proteins like lepA, rtxA, pckA, tuf, and tpiA that are linked to bacterial virulence and potential gallstone formation, with lepA being upregulated in gallstone bile compared to polyp bile. Furthermore, our analysis of the host proteome in gallstone bile revealed enhanced inflammatory molecular profiles, including innate immune molecules against microbial infections. Gallstone bile exhibited overrepresented pathways related to blood coagulation, folate metabolism, and the IL-17 pathway. However, we observed suppressed metabolic activities, particularly catabolic metabolism and transport activities, in gallstone bile compared to polyp bile. Notably, acute cholelithiasis bile demonstrated significantly impaired metabolic activities compared to chronic cholelithiasis bile.

Conclusion

Our study provides a comprehensive metaproteomic analysis of bile samples related to gallstone disease, offering new insights into the microbiome-host interaction and gallstone formation mechanism.

Intractable Biliary Candidiasis in Patients with Obstructive Jaundice and Regional Malignancy: A Retrospective Case Series

BACKGROUND

Candida species are infrequently grown in bile cultures. An association between biliary candidiasis and regional malignancy may exist. The role of fungus membranes in frequent biliary stent occlusion is also presented in this case series.

METHODS

We retrospectively identified patients who underwent percutaneous trans-hepatic cholangiogram (PTC) for obstructive jaundice between January 2014 and January 2019. The results of bile cultures - obtained by PTC - for all patients were analyzed, and patients with fungus growth were determined; their medical records were reviewed.

RESULTS

A total of 71 patients with obstructive jaundice underwent PTC between January 2015 and January 2019. Five patients (all male; mean age 55.8 years) had candida species growth in bile cultures. Two patients were diagnosed with cholangiocarcinoma, one with adenocarcinoma of the head of the pancreas, one with gallbladder cancer, and one with locally advanced gastric adenocarcinoma. Formation of fungal balls predisposed to frequent PTC drain clogging. Eradication of Candida was achieved in 4 patients after 10 days to 3 weeks of antifungal therapy.

CONCLUSION

We present a case series of biliary candidiasis in patients with obstructive jaundice and regional malignancy. We suggest that patients with obstructive jaundice and regional malignancy should be screened for biliary candidiasis. Persistent cholestasis may be caused by the recurrent formation of fungal membranes (balls).

Systemic Lupus Erythematosus-associated Acute Acalculous Cholecystitis Successfully Treated by a Corticosteroid Combined with Azathioprine

A 69-year-old Japanese woman was transferred to our hospital due to pancytopenia with a fever. She had Murphy's sign, and computed tomography showed pleural effusion and a swollen gallbladder without gallstones. We diagnosed her with systemic lupus erythematosus (SLE)-associated acute acalculous cholecystitis (AAC). Partly because her clinical and laboratory findings were not serious enough to warrant immediate surgical intervention, and partly because her poor general condition made her ineligible for surgery, surgical therapy was not selected. Corticosteroid therapy was performed with azathioprine, and the swelling in her gallbladder improved. As a conservative therapy for SLE-associated AAC, corticosteroid therapy combined with azathioprine might be beneficial.

Acute acalculous cholecystitis due to Fusarium species and review of the literature on fungal cholecystitis

Fungal cholecystitis is an uncommon entity, and no cases of cholecystitis associated with mould infection have been reported. We present a case of acute Fusarium cholecystitis in a cytopenic patient with leukaemia who had disseminated fusariosis. We also review the published cases of fungal cholecystitis, which is most often caused by Candida species. Although it is rare, fungal cholecystitis should be part of the differential diagnosis of acute cholecystitis in high-risk patients with predisposing factors for opportunistic fungal infections.

Clinical significance of isolated biliary candidiasis in patients with unresectable cholangiocarcinoma

BACKGROUND

The frequency of isolated biliary candidiasis is increasing in cancer patients. The clinical significance of isolated biliary candidiasis remains unclear. We analyzed the risk factors of biliary candidiasis and outcomes of the patients with unresectable cholangiocarcinoma after percutaneous transhepatic biliary drainage (PTBD).

METHODS

Among 430 patients who underwent PTBD between January 2012 and March 2015, 121 patients had unresectable cholangiocarcinoma. Bile and blood samples were collected for consecutive fungal culture.

RESULTS

The study cohort included 49 women and 72 men with a median age of 71 years. Multivariate analysis showed that cancer progression (P=0.013), concurrent presence of another microorganism (P=0.010), and previous long-term (>7 days) antibiotic use (P=0.011) were potential risk factors of biliary candidiasis. Chemotherapy was not associated with overall biliary candidiasis (P=0.196), but was significantly related to repeated biliary candidiasis (P=0.011). Patients with isolated biliary candidiasis showed remarkably reduced survival compared with those without [median overall survival (OS): 32 vs 62 days, P=0.011]. Subgroup analysis was also performed. Patients with repeated candidiasis had markedly decreased survival compared with those with transient candidiasis (median OS: 30 vs 49 days, P=0.046). Biliary candidiasis was identified as a poor prognostic factor by univariate and multivariate analyses (P=0.033). Four cases of repeated candidiasis (4/19, 21%) showed Candida species in consecutive blood culture until the end of the study, but others showed no candidemia.

CONCLUSIONS

Isolated biliary candidiasis may be associated with poor prognosis in patients with unresectable cholangiocarcinoma. Especially, repeated biliary candidiasis may have the possibility of progression to candidemia. We suggest that biliary dilatation treatment or antifungal agents might be helpful for patients with biliary candidiasis.

Intra-abdominal fungal infections

PURPOSE OF REVIEW

The clinical spectrum of intra-abdominal fungal infections has not been systematically analyzed in the literature.

RECENT FINDINGS

Even though intra-abdominal fungal infections have been recognized with increasing frequency in the recent years, most clinical experience is limited to case reports or uncontrolled case series. These infections are more common than clinically recognized disease. The clinical presentation varies broadly depending on the organism and host's immune status, but it is frequently severe, difficult to treat, and associated with significant morbimortality. Predisposing factors, clinical characteristics, and advances in the management are discussed.

SUMMARY

Intra-abdominal fungal infections are increasingly important in clinical practice. Early recognition and a combined treatment approach, usually consisting of surgical intervention and systemic antifungal therapy, are required for improved outcomes.

Mycoplasma salivarium detected in a microbial community with Candida glabrata in the biofilm of an occluded biliary stent

Mycoplasma salivarium, preferentially an inhabitant of the human oral cavity, has rarely been found in other locations associated with disease. We describe here, for what is believed to be the first time, the detection of M. salivarium, together with Candida glabrata, in an occluded biliary stent of an icteric, cholestatic patient.

Prevalence, associations, and trends of biliary-tract candidiasis: a prospective observational study

BACKGROUND

Biliary obstruction and cholangitis are common problems in gastroenterology. Infections of the biliary tract with Candida and other fungal species have increasingly been seen in the last few years.

OBJECTIVE

To investigate the prevalence, associations, and trends of biliary-tract candidiasis.

DESIGN

A prospective, observational, diagnostic study.

SETTING

University Hospital, Muenster, Germany.

PATIENTS

Consecutive patients undergoing ERCP for various indications.

RESULTS

In 54 of 123 patients, we found Candida species in bile samples (44%). In only 7 patients, candidiasis was suspected on endoscopy before mycologic proof. Only 4 of these 7 patients were correctly diagnosed with biliary candidiasis by simple morphologic aspects. The fungus was mainly differentiated as Candida albicans or Candida glabrata and rarely as Candida parapsilosis, Candida tropicalis, or other subspecies. Immunosuppression for various reasons was significantly associated with bile-duct candidiasis (P < .02). No significant association was found between positive fungal cultures and prior endoscopic sphincterotomy (P = .0824) or prior ERCP (P = .1152). Biliary candidiasis was neither associated with positive fungal cultures of buccal smears (P = .0722) nor with positive findings in stool samples (P = .0860).

LIMITATIONS

Highly selected patient population. Buccal smears and stool samples were not obtained from all patients. Contamination artifacts cannot totally be excluded with the ERCP procedure.

CONCLUSIONS

Candida species very frequently can be detected in the bile. Positive fungal cultures of bile samples are not just contamination artifacts. This has to be taken into account when designing an anti-infectious treatment for recurrent cholangitis or even more cholangiosepsis. Especially in immunosuppressed patients or recipients of long-term antibiotic therapy, physicians should screen for biliary-tract candidiasis during endoscopic examination.

[Is the use of antifungal management advisable in critical patients with positive isolation of Candida spp. from intraabdominal clinical samples?]

The diagnostic and therapeutic approaches to IFI have changed significantly in recent years, fostered by the introduction of new diagnostic methods and new antifungal products. The diagnosis of invasive candidiasis (IC) involves both clinical and laboratory parameters, but neither of these are specific and the majority of the yeast isolated showed only colonization but not true infection. This situation occurs in critical care setting especially when surgical drainages are used. A substantial number of patients become colonized with Candida spp. after abdominal surgery, but only a minority subsequently develops invasive candidiasis. The clinical and microbiological diagnosis of Candida peritonitis remains problematic. It is still unclear which patients with may benefit from antifungal treatment. Antifungal therapy can be suggested in critically ill patients with peritonitis where Candida is diagnosed based on perioperatively sampled peritoneal fluid. Since fungal infection is also a relatively common complication of severe pancreatitis it seems reasonable that fungal prophylaxis may be an important component of management although actually there is no evidence to support this approach. However, the high mortality associated with IC is partly correlated to the difficulties of making an early diagnosis, thus, to improve earlier diagnosis and survival of IC, new nonculture-based microbiological tools such as Candida albicans germ tube antibodies (CAGTA) and/or polymerase chain reaction (PCR) techniques for the detection of fungal-specific DNA should be used in conjunction with recent published "Candida score" prediction rule. An algorithm based on this approach has been provided to assess early treatment in surgical patients with yeasts isolated from intra-abdominal samples.

Candida Cholecystitis in a Diabetic Patient on Chronic Peritoneal Dialysis

Acute cholecystitis caused by Candida glabrata is a rare condition. We present a 60‐year‐old female patient with end‐stage renal failure on continuous ambulatory peritoneal dialysis experiencing high fever, shock, and leukocytosis. There was no evidence of continuous ambulatory peritoneal dialysis peritonitis. Abdominal computed tomography showed evidence of acute cholecystitis. A bile culture from percutaneous gallbladder drainage and a urine culture both showed growth of C. glabrata. However, after treatment with oral fluconazole and broad‐spectrum antibiotics, the patient died of septic shock.

Colecistitis aguda e infección de la vía biliar por Candida

Candida biliary tract infection is a rare disease. Most of the reported cases have been diagnosed in patients with surgery or invasive procedures of the biliary tract, critical illness, immunosuppression or antibiotic treatment. This report deals with an 85 years old female patient with Candida albicans cholecystitis without previous risk factors and with a literature review on the subject. Only four patients without risk factors have been so far reported.

The microbiological impact of pre-operative biliary drainage on patients undergoing hepato-biliary-pancreatic (HPB) surgery

BACKGROUND

The merit of pre-operative biliary drainage in managing hepatic, biliary or pancreatic patients remains unclear with previous studies demonstrating significant increases in bacterobilia.

AIMS

To establish if pre-operative biliary drainage was associated with (i) a change in bacterial flora, (ii) post-operative sepsis and (iii) to ascertain if a modification of antibiotic prophylaxis was warranted.

METHODS

Data were collected on 331 patients undergoing hepatic, biliary or pancreatic surgery for malignant obstruction between August 2000 and June 2005. Microbiological data from intra-operative bile, post-operative wounds, blood cultures, urine and sputum were analysed. All episodes of pre-operative endoscopic retrograde cholangiopancreatography (ERCP), stenting and percutaneous drainage were documented.

RESULTS

One hundred and sixty two patients had ERCP prior to surgery and 154 had surgery only. In comparison to patients who had surgery alone stented patients had significantly increased rates of bacterobilia (40 vs. 85%) and fungobilia (8 vs. 34%, both P < 0.001). Pre-operative biliary drainage significantly increased post-operative sepsis, wound infections and prolonged in-patient stay (P < 0.05). The most common organisms cultured were coliforms and enterococcus with percutaneous transhepatic cholangiography (PTC) highly significant for the development of MRSA sepsis.

CONCLUSIONS

Pre-operative biliary drainage is associated with a high incidence of bacterobilia and fungal colonization. Pre-operative biliary drainage should be utilized selectively, with modification of antibiotic prophylaxis according to patient characteristics.

Biliary candida infections in primary sclerosing cholangitis

BACKGROUND/AIMS

Patients with Primary Sclerosing Cholangitis (PSC) frequently develop dominant stenoses of the bile ducts and bacterial infections represent a major problem in such patients. In the present study, the role of fungal infections of the bile ducts has been evaluated.

METHODS

In a prospective non-randomized trial, in 67 consecutive patients with PSC, 148 bile samples, each taken at one endoscopic examination, were microbiologically analysed.

RESULTS

Candida species were found in 8/67 patients whereas Aspergillus was not detected. Seven patients with biliary Candida had a dominant stenosis and one had a wide papillotomy with chronic ascending cholangitis. Altogether 7/49 of patients with dominant stenosis and 1/18 of patients without dominant stenosis had Candida in their bile. All patients with biliary Candida intermittently had received antibiotics and had advanced disease with cholestasis. Candida disappeared spontaneously in 2/7 patients, cleared after antifungal treatment in 2, and persisted in 3 patients. Patients with biliary Candida had more severe cholangitis with higher CRP and serum bilirubin compared to those without Candida infection.

CONCLUSIONS

This is the first report on the identification of Candida species in the bile of patients with PSC. Apart from bacterial also fungal infection of the bile ducts should be considered in the treatment of such patients.

Biliary tract candidiasis: diagnostic and therapeutic approaches in a case series

BACKGROUND

Biliary obstruction with its wide range of potential causes is a common disorder in gastroenterology. Infections of the biliary tract with Candida and other fungal species leading to obstructive jaundice have increasingly been recognized in the last few years. Besides a few case reports, there are few data in the literature giving us an idea how to diagnose and treat these patients.

METHODS

We report on a series of seven patients suffering from biliary tract candidiasis who were diagnosed and treated at our institution. Predisposition factors, reliability of various diagnostic modalities, and treatment options based on our own experience are presented and discussed.

RESULTS

Besides the general diagnostic modalities such as laboratory findings or ultrasonography, we often observed mycelia in the bile duct system endoscopically. Typical morphological changes in peripheral bile ducts could be detected during endoscopic retrograde cholangiopancreatography (ERCP). Aspiration of bile and subsequent microbiological analysis in combination with ERCP findings revealed diagnosis of bile duct candidiasis in all cases. Treatment included both antiinfectious drugs and endoscopic therapy such as bile duct drainage, lavage, or débridement. With respect to fungal eradication, therapy was successful in 71% of cases as proven by microbiological analysis of bile aspirates. Since many of these patients suffer not only from biliary mycosis but also from disease necessitating immunosuppression, the prognosis was poor in some cases.

CONCLUSION

Biliary tract candidiasis because of immunosuppression is an increasingly recognized disease and remains a major clinical challenge. Besides laboratory analysis and ultrasonography, diagnostic modalities should include aspiration of bile during ERCP and microbiological analysis. Antiinfectious drug treatment as the main therapeutic column for biliary candidiasis should be complemented by endoscopic intervention.

Candida peritonitis in a patient with necrotising cholecystitis and pancreatitis

An 80-year-old patient in previously excellent state of health presented with septic syndrome for gangrenous cholecystitis and concomitant pancreatitis. Diagnostic paracentesis revealed microbiological evidence of Candida albicans in the abdominal cavity. Laparoscopic cholecystectomy was performed and examination of histological specimens confirmed peritonitis by fungal perforation of the gall bladder. In a complicated postoperative course the patient was finally cured choosing voriconazole (Vfend) for antimycotic therapy.

Can yeast isolation in peritoneal fluid be predicted in intensive care unit patients with peritonitis?

OBJECTIVE

To generate and validate a predictive score of yeast isolation based on independent risk factors of yeast isolation in intensive care unit patients with peritonitis.

DESIGN

Retrospective cohort study to determine independent risk factors of yeast isolation, generation of the score, and validation in a prospective cohort of patients with peritonitis.

SETTING

Tertiary-care, university-affiliated hospital.

PATIENTS

Two hundred twenty-one patients with peritonitis hospitalized in a surgical intensive care unit between 1994 and 1999 for the retrospective cohort and 57 patients in the prospective cohort (2000).

MEASUREMENTS AND MAIN RESULTS

Four independent risk factors of yeast isolation in peritoneal fluid (similar odds ratio) were found in the retrospective cohort: female gender, upper gastrointestinal tract origin of peritonitis, intraoperative cardiovascular failure, and previous antimicrobial therapy at least 48 hrs before the onset of peritonitis. A score based on the number of risk factors was constructed (grade A = zero or one risk factor, grade B = at least two risk factors, grade C = at least three risk factors, and grade D = four risk factors), and validated in the prospective cohort. For a grade C score, sensitivity was 84%, specificity was 50%, positive and negative predictive values were 67% and 72%, respectively, and overall accuracy was 71%.

CONCLUSIONS

Four independent risk factors of yeast isolation in the peritoneal fluid were identified in critically ill surgical patients with peritonitis. The presence of at least three of these factors (grade C score) was associated with a high rate of yeast detection. This approach could be helpful to initiate early antifungal therapy in this patient population.

Deeply invasive candidiasis

The incidence of invasive candidiasis is on the rise because of increasing numbers of immunocompromised hosts and more invasive medical technology. Recovery of Candida spp from several body sites in a critically ill or immunocompromised patient should raise the question of disseminated disease. Although identification to the species level and antifungal susceptibility testing should guide therapy, at this time amphotericin B preparations are the usual initial therapy for severe life-threatening disease. Azole therapy has an expanding body of evidence that proves it is as effective as and safer than amphotericin B therapy. Some forms of candidiasis (e.g., those with ocular, bone, or heart involvement) require a combined medical and surgical approach.

Clinical determinants for the recovery of fungal and mezlocillin-resistant pathogens from bile specimens

We conducted a retrospective analysis of all bile specimens obtained for routine cultures from January 1995 through December 1999 at our tertiary care hospital. Results of microbiologic testing were linked to clinical parameters gathered by means of chart review. A total of 722 isolates were cultured from 345 of 454 bile specimens obtained from 288 individual patients. Prior receipt of a >7-day course of antibiotics (odds ratio [OR], 5.7), extensive leukocytosis (leukocyte count, >20,000 cells/microL) on admission (OR, 7.8), endoscopic or percutaneous biliary manipulation during the previous 14 days (OR, 2.9), and treatment in an internal medicine ward (OR, 2.5) were independent factors significantly associated (Pless-than-or-eq, slant.05) with recovery of Candida species from bile specimens. Culture of mezlocillin-resistant bacteria from bile specimens was independently associated with the specimen having been obtained >1 week after admission (OR, 3.8), lack of history of endoscopic biliary drainage (OR, 3.2), and high serum aspartate aminotransferase levels (>72 U/L) on admission (OR, 2.6). Prospective studies are warranted to evaluate accordingly adjusted empiric therapies for biliary infections.

Acute (ascending) cholangitis

Cholangitis is an infection of an obstructed biliary system, most commonly due to common bile duct stones. Bacteria reach the biliary system either by ascent from the intestine or by the portal venous system. Once the biliary system is colonized, biliary stasis allows bacterial multiplication, and increased biliary pressures enable the bacteria to penetrate cellular barriers and enter the bloodstream. Patients with cholangitis are febrile, often have abdominal pain, and are jaundiced. A minority of patients present in shock with hypotension and altered mentation. There is usually a leukocytosis, and the alkaline phosphatase and bilirubin levels are generally elevated. Noninvasive diagnostic techniques include sonography, which is the recommended initial imaging modality. Standard CT, helical CT cholangiography, and magnetic resonance cholangiography often add important information regarding the type and level of obstruction. Endoscopic sonography is a more invasive means of obtaining high-quality imaging, and endoscopic or percutaneous cholangiography offers the opportunity to perform a therapeutic procedure at the time of diagnostic imaging. Endoscopic modalities currently are favored over percutaneous procedures because of a lower risk of complication. Treatment includes fluid resuscitation and antimicrobial agents that cover enteric flora. Biliary decompression is required when patients do not rapidly respond to conservative therapy. Definitive therapy can be performed by a surgical, percutaneous, or endoscopic route; the last is favored because it is the least invasive and has the lowest complication rate. Overall prognosis depends on the severity of the illness at the time of presentation and the cause of the biliary obstruction.

Fungal infection in the intensive care unit

Fungal infection in critically ill patients is an increasingly prevalent problem. Candida spp. cause the majority of these infections in ICU. They occur most commonly in patients with severe underlying illness, multiple courses of antibiotics and intravascular catheters. Clinical diagnosis is difficult due to nonspecific signs and the frequent occurrence of widespread superficial colonization with Candida spp. in ventilated patients. Most patients are diagnosed using inferential evidence of infection, such as persistent pyrexia despite antibiotics, raised serum C-reactive protein and the presence of individual risk factors. Amphotericin B and fluconazole are the most commonly used anti-fungals dependent on the identity of the fungus. Most of these infections are endogenous; however, a proportion may be caused via the hands of healthcare staff or contaminated medical equipment.