A Case of Sepsis Due to Candida krusei Peritonitis in the Intensive Care Unit (ICU)

Abstract

INTRODUCTION: Invasive candidiasis(IC) is a serious health-care associated infection rarely suspected as a cause of peritonitis.We present a case of Candida krusei peritonitis in a septic,cirrhotic patient. CASE PRESENTATION: 40 year-old male,alcohol abuser,presented with abdominal pain,fever and hypotension.Required pressors,renal replacement therapy(RRT) for renal failure and intubation for acute respiratory failure and sepsis.Abdomen ultrasound showed ascites,IV ceftriaxone was started for suspected spontaneous bacterial peritonitis.Diagnostic paracentesis revealed 11201 leukocytes(64% neutrophils),culture was sterile.Antibiotics were escalated to IV vancomycin,cefepime and metronidazole when patient did not improve.Patient was subsequently extubated,pressors and RRT were discontinued.Antibiotics were stopped after seven days.The patient spiked high fevers and worsening leukocytosis the next day.Repeat paracentesis showed 3116 leukocytes(81% neutrophils).Antibiotics were resumed but sepsis continued.Preliminary paracentesis culture revealed yeast.IV antibiotics were switched to IV anidulafungin.Finally culture grew Candida krusei.Five days later,a third paracentesis showed 626 leukocytes(41% neutrophils),culture was negative.Patient improved clinically and completed 14 days of anidulafungin. DISCUSSION: IC is a serious nosocomial infection,frequently underdiagnosed and associated with a mortality exceeding 50%.IC is an uncommon cause of peritonitis.C. krusei is rarely seen except in hematologic malignancies and transplant recipients.In a septic ICU patient worsening on broad spectrum antibiotics,either source control or resistant organisms are the most likely cause.IC is difficult to diagnose given low sensitivity of lab tests.Early recognition of risk factors in ICU patients is crucial for management and outcome.Changing epidemiology has shifted IC to non-albicans Candida spp,which are more likely to have decreased susceptibility or been resistant to triazoles.Therefore IC treatment guidelines have recommended empiric echinocandins as first line treatment for critically ill patients.Recent meta-analysis of randomized trials indicated echinocandins were associated with decreased mortality in any patient with IC compared to triazoles or amphotericin B.Initial management should include Candida speciation to guide early and appropriate antifungal therapy. CONCLUSIONS: In septic ICU patients who are not improving on broad spectrum antibiotics,IC should be considered as a possible etiology and if suspected,empiric echinocandins should be started.