Candida Case

[Praziquantel86]

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Hi all, I ran across a (somewhat) interesting case at my hospital today, just thought I'd see your opinions on it.

Patient is a 38 year-old male who was admitted to a hospital in the Southwest for feeling generally unwell. No significant medical or family history. Social history is positive for alcoholism, in the amount of 5-6 beers and/or bottle of vodka per night. He had recently traveled to Mexico and was due to fly back home later that week. Upon admission, the patient is grossly jaundiced and has multiple spider-web angiomas. He was transferred to a hospital closer to home late last week.

Initial labs are relatively normal (LFT's are only slightly elevated), with the exception of total bilirubin (hovering around 30). He's transferred to the transplant service, where kidney function begins to decline (GFR is currently at 15). ID service was consulted, fungal infection is presumed, he is started on liposomal amphotericin. Later cultures show Candida albicans and gram positive cocci in clusters. Vanco was added, he is still on amphotericin (three days after cultures came back).

My question is this: once C. albicans was isolated, why wouldn't he have been switched to either fluconazole or an echinocandin (we have micafungin on formulary). The ID service has recommended 3-4 weeks of amphotericin, and no one can quite figure out why. Any ideas?

 

[bigpharmD]

Hi all, I ran across a (somewhat) interesting case at my hospital today, just thought I'd see your opinions on it.

Patient is a 38 year-old male who was admitted to a hospital in the Southwest for feeling generally unwell. No significant medical or family history. Social history is positive for alcoholism, in the amount of 5-6 beers and/or bottle of vodka per night. He had recently traveled to Mexico and was due to fly back home later that week. Upon admission, the patient is grossly jaundiced and has multiple spider-web angiomas. He was transferred to a hospital closer to home late last week.

Initial labs are relatively normal (LFT's are only slightly elevated), with the exception of total bilirubin (hovering around 30). He's transferred to the transplant service, where kidney function begins to decline (GFR is currently at 15). ID service was consulted, fungal infection is presumed, he is started on liposomal amphotericin. Later cultures show Candida albicans and gram positive cocci in clusters. Vanco was added, he is still on amphotericin (three days after cultures came back).

My question is this: once C. albicans was isolated, why wouldn't he have been switched to either fluconazole or an echinocandin (we have micafungin on formulary). The ID service has recommended 3-4 weeks of amphotericin, and no one can quite figure out why. Any ideas?

hmm is there an MIC? Allergies? WE commonly put our ESLDs on fungal prophy due to translocation from the biliary tract and take it off post transplant depending on how the surgery went. We have never used ampho in an ESLD patient or a post transplant patient.

 

[StaviZFingerZ]

Does the ID suspect Coccidioides immitis - San Joaquin Valley Fever?

 

[bigpharmD]

yeah they have to think there is something else going on...but why get cultures if you dont trust them...?

 

[StaviZFingerZ]

yeah they have to think there is something else going on...but why get cultures if you dont trust them...?

Well, not everything grows ..you know that. I can't wait for the PCR technology to advance.

 

[Praziquantel86]

I didn't see any allergies noted other than codeine, I'm not sure about the MIC's (I don't think that we commonly get them for fungi). He hasn't had a transplant yet, I have a feeling that the alcoholism would probably prevent him from getting one.

I initially thought coccidiodes as well, but so far nothing has shown up in cultures. I'm not too familiar with coccidiodies though, does it cause acute organ failure like this?

 

[StaviZFingerZ]

If it was straight Candidiasis due to Albican, fluconazole will do... no need for echinocandin. Heck, for long term chronic coccidioidomycosis, fluconazole should do.

 

[bigpharmD]

I didn't see any allergies noted other than codeine, I'm not sure about the MIC's (I don't think that we commonly get them for fungi). He hasn't had a transplant yet, I have a feeling that the alcoholism would probably prevent him from getting one.

I initially thought coccidiodes as well, but so far nothing has shown up in cultures. I'm not too familiar with coccidiodies though, does it cause acute organ failure like this?

well that could be from his liver disease, and fungal infections are quite common in ESLD...prob no MIC with albicans

 

[prevacid]

i wouldve putve on a broad spectrum agent initially in case it wasnt fungus, anyhoo, i would think its ok to switch to diflucan

but wat do i know, im not in clinical

 

[Priapism321]

Well, not everything grows ..you know that. I can't wait for the PCR technology to advance.

Then why bother getting them if you are just going to use the cop out in the end? Especially in the setting where something does grow?

 

[StaviZFingerZ]

I initially thought coccidiodes as well, but so far nothing has shown up in cultures. I'm not too familiar with coccidiodies though, does it cause acute organ failure like this?

ehh..not that I know of. DX requires serological test for antibody or biopsy of infected tissue. Usually pneumonia or CNS infection...dang I still remember this from studying for the CA board heh.. That was long ago.


Oh..another possibility..will this patient ambulate and go home? The ID could have some vested interest in doing outpatient infusion... I would thin Ampho-B liposomal would be more profitable than Fluconazole oral.

 

[bigpharmD]

Hi all, I ran across a (somewhat) interesting case at my hospital today, just thought I'd see your opinions on it.

Patient is a 38 year-old male who was admitted to a hospital in the Southwest for feeling generally unwell. No significant medical or family history. Social history is positive for alcoholism, in the amount of 5-6 beers and/or bottle of vodka per night. He had recently traveled to Mexico and was due to fly back home later that week. Upon admission, the patient is grossly jaundiced and has multiple spider-web angiomas. He was transferred to a hospital closer to home late last week.

Initial labs are relatively normal (LFT's are only slightly elevated), with the exception of total bilirubin (hovering around 30). He's transferred to the transplant service, where kidney function begins to decline (GFR is currently at 15). ID service was consulted, fungal infection is presumed, he is started on liposomal amphotericin. Later cultures show Candida albicans and gram positive cocci in clusters. Vanco was added, he is still on amphotericin (three days after cultures came back).

My question is this: once C. albicans was isolated, why wouldn't he have been switched to either fluconazole or an echinocandin (we have micafungin on formulary). The ID service has recommended 3-4 weeks of amphotericin, and no one can quite figure out why. Any ideas?

this is an alcoholic these days.......uh oh

 

[StaviZFingerZ]

well that could be from his liver disease, and fungal infections are quite common in ESLD...prob no MIC with albicans

yeah..why run MIC for albican...I can see running it for Glabrata to see if fluconazole would be feasible.

 

[Praziquantel86]

Oh..another possibility..will this patient ambulate and go home? The ID could have some vested interest in doing outpatient infusion... I would thin Ampho-B liposomal would be more profitable than Fluconazole oral.

I guess that is a possibility, although I doubt this guy is going to be doing much walking anytime soon.

this is an alcoholic these days.......uh oh

Isn't there a multiply by 3 rule for anything the patient tells you about drinks that they have in a night? Even so, a handle of Svedka a night is no small shakes.

 

[Praziquantel86]

If it was straight Candidiasis due to Albican, fluconazole will do... no need for echinocandin. Heck, for long term chronic coccidioidomycosis, fluconazole should do.

So when would it be appropriate to use an echinocandin? Unknown candida, or any unknown fungal infection?

 

[Priapism321]

Isn't there a multiply by 3 rule for anything the patient tells you about drinks that they have in a night?

Same rule applies when a woman tells you how many individuals she has slept with....

 

[Priapism321]

So when would it be appropriate to use an echinocandin? Unknown candida, or any unknown fungal infection?

Candida glabrata can be dose dependently susceptible to fluconazole. If it is not, an echinocandin should be used. Empirically, patients at risk should receive an echinocandin until the culture results return.

 

[bigpharmD]

So when would it be appropriate to use an echinocandin? Unknown candida, or any unknown fungal infection?

we typically use an echino....🙄

 

[Priapism321]

we typically use an echino....🙄

Weak....

 

[bigpharmD]

Weak....

+daptomycin +dorpenem

 

[StaviZFingerZ]

So when would it be appropriate to use an echinocandin? Unknown candida, or any unknown fungal infection?

ahhh..I'm glad you asked. C.albican can be covered with fluconazole and it's the most cost effective way to go. But we know C.Krusei and C.glabrata most likely will require echinocandin. Glabrata with low MIC can be had with fluconazole.

Now..when to use echinocandin? Well, if your institution rarely sees Non albicans, there's no need to use echinocandin unless the patient is has a history of non albican infection. If your institution has a high rate of non-albicans.. (what % would you consider it as high? debatable), then perhaps empiric therapy with echinocandin is warranted until the c/s can identify albican vs. non albicans. That's why PCR which can identify bugs with in 2 hours will be a very valuable tool in near future.

I am going to ask my ID pharmacist about the ampho-B and when to use echinocandin empirically. She's young but everytime I talk to her, I get off the phone humbled having learned a new thing.

 

[StaviZFingerZ]

Candida glabrata can be dose dependently susceptible to fluconazole.

I said that already!!

If it is not, an echinocandin should be used. Empirically, patients at risk should receive an echinocandin until the culture results return.

I think this is where instiutional variation takes place. For your joint..probably. But for a 100 bed community hospital with low non albican..I would say no.

 

[StaviZFingerZ]

+daptomycin +dorpenem

I will kill you!

Oh, it's Doripenem.

 

[Priapism321]

I think this is where instiutional variation takes place. For your joint..probably. But for a 100 bed community hospital with low non albican..I would say no.

Please tell me why, when the IDSA gives us validated risk factors by which to make such a decision? Rural hospitals probably kill more patients and misdiagnose/mismanage to a degree that it should never be investigated (well, unless you operate in the interest of the patient). 100 bed community hospital pharmacists and physicians probably do not know how to access the 2009 Candida guidelines.

 

[Praziquantel86]

ahhh..I'm glad you asked. C.albican can be covered with fluconazole and it's the most cost effective way to go. But we know C.Krusei and C.glabrata most likely will require echinocandin. Glabrata with low MIC can be had with fluconazole.

Now..when to use echinocandin? Well, if your institution rarely sees Non albicans, there's no need to use echinocandin unless the patient is has a history of non albican infection. If your institution has a high rate of non-albicans.. (what % would you consider it as high? debatable), then perhaps empiric therapy with echinocandin is warranted until the c/s can identify albican vs. non albicans. That's why PCR which can identify bugs with in 2 hours will be a very valuable tool in near future.

I am going to ask my ID pharmacist about the ampho-B and when to use echinocandin empirically. She's young but everytime I talk to her, I get off the phone humbled having learned a new thing.

Fair enough, thanks for the info.

I'm hoping to get an answer on this soon...I only work once a week during the semester so I tend to miss all of the loose ends coming together.

 

[Priapism321]

I think this is where instiutional variation takes place. For your joint..probably. But for a 100 bed community hospital with low non albican..I would say no.

Oh goodness, just realized who you were. Foot exiting mouth now.

 

[StaviZFingerZ]

Please tell me why, when the IDSA gives us validated risk factors by which to make such a decision? Rural hospitals probably kill more patients and misdiagnose/mismanage to a degree that it should never be investigated (well, unless you operate in the interest of the patient). 100 bed community hospital pharmacists and physicians probably do not know how to access the 2009 Candida guidelines.

Why? well, you'll see that fluconazole along with echinocandins are recommended for empiric therapy in the new guidelines. And do you not agree that the guidelines, especially IDSA guidelines should be followed with a strong emphasis on evaluation of the local C/S trend and patterns?
I also believe the authors responsible for the guidelines practice primarily in tertiary setting where you're likely to see a higher rate of resistance pattern compared to a smaller community hospitals.

We have actually discussed this issue and the consensus was that "yeah..we know what the guideline says....but for many of our smaller facilities with a low rate of non albicans, fluconazole is the drug of choice." Of course for larger facilities, the rate of echinocandin use is higher yet we have utilized PNA-FISH for earlier dection to differentiate albican vs. non albincans. Saves about 2 days worth of echinocandins if it's albican.

 

[StaviZFingerZ]

Oh goodness, just realized who you were. Foot exiting mouth now.

Dang it..you made me type all that chit above!!

 

[njac]

I'm reading this on the blackberry with a raging headache - just wantd to add that I've had cocci.

 

[StaviZFingerZ]

I'm reading this on the blackberry with a raging headache - just wantd to add that I've had cocci.

Dang..for reals?

 

[njac]

Disseminated - diagnosed by a med student. 19 yo with 4 day hx of severe joint pain and big soft/deep bruises on legs.

I'd just gotten back from MD and thought it was Lyme. Clean CXR

 

[Sparda29]

same rule applies when a woman tells you how many individuals she has slept with....

rofl!

 

[nikkai]

Well, not everything grows ..you know that. I can't wait for the PCR technology to advance.

Advance = become more affordable? =)

From my days as a lab rat during undergrad till now, reading up on the tech, it's still the same - with enhancements in computer/assay hand-shake.

It's just ridiculously expensive. And my buddy, a local surfer in the Bay and discoverer of PCR, (which he thought of while driving to catch the next big wave) is still kick his own ***** about selling it for so cheaply to that Swiss company.



*edit* What the deuce?! SDN censor threw five "*" in my three letter swear word? Boooo censorship. It's even de-identifying my word to the point of confusion.

 

[StaviZFingerZ]

Advance = become more affordable? =)

From my days as a lab rat during undergrad till now, reading up on the tech, it's still the same - with enhancements in computer/assay hand-shake.

It's just ridiculously expensive. And my buddy, a local surfer in the Bay and discoverer of PCR, (which he thought of while driving to catch the next big wave) is still kick his own ***** about selling it for so cheaply to that Swiss company.



*edit* What the deuce?! SDN censor threw five "*" in my three letter swear word? Boooo censorship. It's even de-identifying my word to the point of confusion.

You're absolutely right. Microbio seems like they're still running on 60's technology. I was pretty exctied about PNA-FISH and am exctied about PCR. When I say advance, I mean being able to id anything that has DNA.

Cost? For large hospitals, I think it'll be cost effective to reduce unnecessary empiric therapy using expensive drugs. But for small facilities, you're right, it can be cost prohibitive.

Man...your buddy invented PCR?????

 

[nikkai]

You're absolutely right. Microbio seems like they're still running on 60's technology. I was pretty exctied about PNA-FISH and am exctied about PCR. When I say advance, I mean being able to id anything that has DNA.

Cost? For large hospitals, I think it'll be cost effective to reduce unnecessary empiric therapy using expensive drugs. But for small facilities, you're right, it can be cost prohibitive.

Man...your buddy invented PCR?????

Heh heh. Pharmacy is a small world, but biotech research was also. But one can only kill so many mice before the formaldehyde starts to get to you.

http://www.karymullis.com/

Relative to all things, the PCR machine is cheap ass hell, compared to all the other "necessary tech" in a hospital. Tech work wise, easy and cheap. Interpretation, pretty easy now with computers. It's the freaking enzymes that ramp up the cost. And since the main enzyme (taq) is caught up in Patent Wars [tm], it will be a while before PCR prices normalize in terms of costs associated to your charge master codes.

But yeah, in terms of speed, you seriously can't beat it right now. There are other ways too you could approach identifying via DNA in the microworld, but it requires more training and labor.

 

[StaviZFingerZ]

Heh heh. Pharmacy is a small world, but biotech research was also. But one can only kill so many mice before the formaldehyde starts to get to you.

http://www.karymullis.com/

Relative to all things, the PCR machine is cheap ass hell, compared to all the other "necessary tech" in a hospital. Tech work wise, easy and cheap. Interpretation, pretty easy now with computers. It's the freaking enzymes that ramp up the cost. And since the main enzyme (taq) is caught up in Patent Wars [tm], it will be a while before PCR prices normalize in terms of costs associated to your charge master codes.

But yeah, in terms of speed, you seriously can't beat it right now. There are other ways too you could approach identifying via DNA in the microworld, but it requires more training and labor.

DOOD!!!

That is the most FREAKING awesome thing!!!!!!!! You know that guy?????

Chit.. can I have your autograph? No really...that's awesome. PCR will rule the Micro and ID in near future. I would put my money on it.

 

[StaviZFingerZ]

Imagine Home PCR kit!!!! diagnose your own infection!!! 👍👍

 

[nikkai]

I guess that's what I bought with the premium cost of living associated with California.

"Be near the stars! Nerd and non-nerd!" =)

And now, I return to even higher cost of living to SF come June.

Man.

But seriously, I agree: all those little MICs that leave us scratch our head why and ramping up costs in terms of therapy - all explained by DNA. Imagine, knowing exactly what the bug is susceptible to b/c we know exactly what variant of what mutation they have.

HIV really paved the way for the role of genomics in ID.

But there is a whole host of controversy regarding that too unfortunately.

 

[PharmDstudent]

But there is a whole host of controversy regarding that too unfortunately.

Why is there controversy?


Oh, and I did an article analysis about enchinocandins vs fluconazole in terms of cost-minimization and testing.

Here's the article.

 

[nikkai]

Why is there controversy?

b/c looking at DNA during a cross section of time may not give you the entire picture of what's going on.

Think back to your old microbio, biochem, and genetics courses:

How many organisms do we actually know the entire genome for?
Out of those organisms, do we know what every single triplet codon codes for?
Does every single bug share the same genome from the sampled source?
How sensitive and specific is our PCR - what's the limiting factor?
etc
etc

 

[PharmDstudent]

b/c looking at DNA during a cross section of time may not give you the entire picture of what's going on.

Think back to your old microbio, biochem, and genetics courses:

How many organisms do we actually know the entire genome for?
Out of those organisms, do we know what every single triplet codon codes for?
Does every single bug share the same genome from the sampled source?
How sensitive and specific is our PCR - what's the limiting factor?
etc
etc

Oh. I see. I thought it was an ethics thing. 😛

 

[Quiksilver]

I was wondering, are we at all concerned that kidney function is declining and we have 2 nephrotoxic drugs on board? i didn't see anyone else mentioning it... I know its a liposomal preparation but aren't we concerned at all?

 

[nikkai]

Patient is a 38 year-old male ...He's transferred to the transplant service, where kidney function begins to decline (GFR is currently at 15).

Big Brother is watching.

 

[njac]

I was wondering, are we at all concerned that kidney function is declining and we have 2 nephrotoxic drugs on board? i didn't see anyone else mentioning it... I know its a liposomal preparation but aren't we concerned at all?

just how nephrotoxic is Vanco?

 

[Priapism321]

just how nephrotoxic is Vanco?

There are contemporary data indicating that when the trough concentration is maintained above 15 mcg/mL, and another nephrotoxic agent is being employed concurrently, the incidence of acute renal injury is as high as 30%. More recent data have also correlated total daily doses greater than 4,000 mg with nephrotoxicity.

 

[bigpharmD]

just switch to daptomycin 6mg/kg....solves everything

 

[bigpharmD]

just how nephrotoxic is Vanco?

I knew this guy in my first year of residency who looked at like 1,000 scr of people on vanc, did some magic math equation to control for variables, and didnt find squat

 

[Priapism321]

I knew this guy in my first year of residency who looked at like 1,000 scr of people on vanc, did some magic math equation to control for variables, and didnt find squat

Hahahahahahahahaha.............

 

[PharmDstudent]

just switch to daptomycin 6mg/kg....solves everything

Except for CAP.

 

[Praziquantel86]

just switch to daptomycin 6mg/kg....solves everything

I think we'd end up blowing our entire pharmacy budget on treating one patient if we did that.

Anyways, somewhat of an update...cultures are now Candida negative, yet Amphotericin remains. They must be suspecting something else at this point.