Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 64-year-old woman is hospitalized for a 2-day history of fever and chills and a 1-day history of hypotension and dyspnea. Medical history is significant for adenocarcinoma of the colon diagnosed 3 weeks ago for which she had a partial colectomy. Her course was complicated by the development of a polymicrobial intra-abdominal abscess. After drainage of the abscess, she received hyperalimentation through a central line catheter and ceftriaxone and metronidazole for 7 days.

On physical examination, temperature is 39.0 °C (102.2 °F), blood pressure is 90/60 mm Hg, pulse rate is 120/min, and respiration rate is 20/min. There are erythema and purulent drainage at the site of a right subclavian central venous catheter. The rest of the examination is normal.

Laboratory studies indicate a leukocyte count of 16,000/µL (16 × 10⁹/L). Serum creatinine level is 3.6 mg/dL (318.2 µmol/L) compared with a value of 1.2 mg/dL (106.1 µmol/L) at admission. Two sets of blood cultures obtained 2 days ago are growing yeast.

In addition to central venous catheter removal, which of the following is the most appropriate treatment option for this patient?

A) Caspofungin
B) Conventional amphotericin B
C) Fluconazole
D) Liposomal amphotericin B
E) Voriconazole

MKSAP Answer and Critique

The correct answer is A) Caspofungin. This item is available to MKSAP 16 subscribers as item 3 in the Infectious Diseases section.

This patient should be treated with caspofungin. She has fungemia, which is most likely caused by Candida species. The most likely source is the central venous catheter, the site of which shows obvious signs of infection including erythema and purulent drainage. She has multiple risk factors for candidemia, including exposure to broad-spectrum antibiotics and having received parenteral nutrition via a central venous catheter. In addition to catheter removal, it is essential that antifungal therapy be instituted promptly. Because she is severely ill, the therapy of choice is an echinocandin agent. The Infectious Diseases Society of America guidelines do not distinguish among the echinocandins; therefore, any of them (caspofungin, anidulafungin, or micafungin) would be appropriate.

Amphotericin B or a lipid formulation of amphotericin B is an alternative choice if there is intolerance to or limited availability of other antifungal agents. This patient has kidney failure, which would be exacerbated by either formulation of amphotericin B.

Fluconazole is recommended for patients who are less critically ill than this patient and who have had no recent exposure to azole antifungal agents. When this patient becomes clinically stable, she can be transitioned from receiving an echinocandin to fluconazole if the isolate is likely to be susceptible to fluconazole.

Voriconazole is effective for the treatment of candidemia, but it offers little advantage over fluconazole and is recommended as step-down oral therapy for selected patients with candidiasis caused by Candida krusei or voriconazole-susceptible Candida glabrata.

Key Point

• Antifungal therapy with an echinocandin agent (caspofungin, anidulafungin, or micafungin) is the treatment of choice for critically ill patients with candidemia.

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