Fungal Infections: When Broad Spectrum Antibiotics Aren t Broad Enough

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1 Fungal Infections: When Broad Spectrum Antibiotics Aren t Broad Enough Minor fungal infections are encountered often in the ED, but fungal infections can also be much more than a nuisance. Life-threatening fungal infections occur in both immunocompromised and healthy individuals. The presenter will convey the depth and breadth of severe fungal infections that may present to the ED. Illustrate historic features that place patients at risk for contracting severe fungal infections. Identify signs and symptoms that can be associated with severe fungal infections. Select the most efficacious therapy and management strategy for patients with severe fungal infections. MO 77 10/27/2014/ 4:00 PM 4:25 PM W175abc McCormick Place (+) No significant financial relationships to disclose (+) John C. Perkins, Jr, MD, FACEP Assistant Professor of Emergency and Internal Medicine Virginia Tech Carilion School of Medicine

2 Fungal Infections: When Broad Spectrum Antibiotics Aren t Broad Enough Jack Perkins, MD, FACEP, FACP Virginia Tech Carilion Emergency Medicine Residency Assistant Professor of Emergency and Internal Medicine Virginia Tech Carilion School of Medicine No Disclosures 1

3 Case Presentation 35 y/o male w/ hx of GSW to abdomen Underwent multiple bowel resections Currently at SNF for TPN , 126, 94/60, 22, 99% Case Presentation Ill-appearing, diaphoretic, pale Benign abdomen, healing surgical wound RUE PICC line no erythema/warmth Indwelling foley with cloudy urine 2

4 Case Presentation Aggressive IVF initiated Broad-spectrum abx Vasopressors not required Admitted to ICU Case Presentation 3 day ICU course Hypotensive majority of admission Vasopressors initiated Patient expired HD # 3 Candida Albicans from 2/2 ED blood cx 3

5 Objectives Discuss patients at risk of invasive fungal infections (IFI) Describe invasive Candida infections Describe invasive Aspergillus infections Recognize implications for ED practice Invasive Candida Infections 75% of all IFI linked to Candida species Mortality 40% Candidemia 10% of + ICU blood cx 4 th most common cause of + blood cx Decreased incidence of C. Albicans Blot S, Edizioni Minerva Medica;

6 Key Point #1 Up to 25% of patients with Candidemia have concurrent bacteremia Richardson M, CMI; 2008 Candida IFI French study of 271 ICU patients 40% patients isolated candidemia 28% invasive candidiasis w/ candidemia 32% invasive candidiasis w/o candidemia Leroy O, Crit Care Med;

7 Candida Focal Source Intra-abdominal (peritoneal fluid) 50% Thorax Skin and soft tissue Leroy O, Crit Care Med; 2009 Changing Epidiemiology Candida Albicans 57% Candida Glabrata 17% Candida Parapsilosis 7% Candida Krusei 5% Candida Tropicalis 4% Leroy O, Crit Care Med;

8 ED Patients at Risk TPN Neutropenic patients Chronic corticosteroid use Transplant patients (esp bone marrow) HIV/AIDS patients Richardson M, CMI; 2008 Risk Factors You May Overlook Indwelling lines Prostheses Burns Diabetes Long-term antibiotics Richardson M, CMI;

9 Key Point #2 Candidemia presentation is often indistinguishable from bacterial sepsis Richardson M, CMI; 2008 Challenges in Diagnosis Blood cx gold standard for invasive disease Blood cultures negative 50% hours to identify Candida species Ostrosky-Zeichner L, Amer Jour Med;

10 Cost of Delay in Diagnosis Morell M, Antimicro Agents and Chemo; 2005 Treatment Echinocandins (e.g. caspofungin) 1 st line Azoles (e.g. fluconazole) resistance Amphotericin B effective but toxicity 9

11 Case Presentation #2 64 y/o male w/ hx of COPD On prednisone and home oxygen 99 4, 104, 118/68, 26, 91% Wheezing throughout, rhonchi RLL Case Presentation #2 CXR unremarkable Tx for COPD exacerbation and admitted Night of admission massive hemoptysis Patient exsanguinates Autopsy shows invasive aspergillus 10

12 Invasive Aspergillus Infections Mortality 75-90% A. Fumigatus most common species Rising incidence in chronic lung disease Blot S, Edizioni Minerva Medica; 2013 Invasive Aspergillus Risk Factors Neutropenia (#1 risk factor) Haematological malignancy Transplant patients (esp. bone marrow) AIDS Chronic corticosteroid use Chronic lung disease Enoch DA, Jour Med Micro;

13 Presentation Asymptomatic in 33% patients Pulmonary most common invasive site Cough, hemoptysis, and fever variable Hypoxia common Enoch DA, Jour Med Micro; 2006 Key Point #3 Invasive pulmonary aspergillosis often resembles bronchopneumonia Kousha M, Eur Resp Rev;

14 Diagnosis Broken down into A) Proven (tissue pathology) B) Probable (risk and sputum culture) C) Possible (risk + suspicious infection) Kousha M, Eur Resp Rev; 2011 Diagnosis CXR often not helpful CT may be diagnostic - Nodules - halo-sign - air-crescent sign Aspergillus ag (galactomannan) helpful Enoch DA, Jour Med Micro;

15 Halo Sign Enoch DA, Jour Med Micro; 2006 Air-Crescent Sign Enoch DA, Jour Med Micro;

16 Voriconazole 1 st line Treatment Amphotericin B effective but toxicity Your Role in IFI Be mindful of risk factors for IFI Sepsis and risk factors consider Candida Bronchopneumonia presentation + risk factors consider Aspergillus If considering IFI contact ID 15

17 Thank you Questions or the slides? 16

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