Septic Shock in an Immunocompromised Hemodialysis Patient

27-year-old male admitted after developing fever and increased white blood cell count during hemodialysis.

Discussion

This high risk, immunocompromised patient was initially treated with broad-spectrum antimicrobials. When he developed septic shock, micafungin was initiated immediately as candidemia accounts for 3-10% of all septic shock and each hour delay in instituting an active antimicrobial reduces survival in both septic shock and candidemia. Ideally, T2Candida would have been collected prior to giving micafungin. However, testing after antifungal dosing retains value because T2Candida positivity is significantly less likely to be impacted by treatment than are blood culture results.

This case highlights how T2Candida can identify candidemia cases that are missed by blood cultures and guide early treatment. T2Candida may be particularly useful in targeting antifungal treatment in patients with septic shock and other risk factors for candidemia.

Presentation

A 27-year-old male admitted after developing fever and increased white blood cell count during hemodialysis. He was given vancomycin at hemodialysis and meropenem upon admission. He had a distant history of a double-lung transplant due to cystic fibrosis and a history of tacrolimus induced renal failure as well as line-associated bloodstream infections due to Enterococcus faecalis, coagulase-negative Staphylococcus, Candida glabrata and S. aureus over the preceding two years. He had been discharged from the hospital 5 days earlier after receiving treatment for Enterobacter cloacae through a peripherally inserted central catheter (PICC).

Shortly after admission, he developed hypotension and respiratory failure requiring vasopressor therapy and mechanical ventilation. Micafungin was initiated within 2 hours, the PICC was discontinued and blood cultures and T2Candida were collected concurrently at 4 hours after the micafungin dose. The T2Candida was positive 4.5 hours later for C. albicans/C. tropicalis.

Patient Selection Criteria

Septic shock in an immunocompromised hemodialysis patient

Evaluation and Treatment Decision

Diagnosis: Septic Shock

Empiric therapy: Initially broad-spectrum antibiotics with the addition of micafungin when septic shock occurred

T2Candida Result: Positive for C. albicans/C. tropicalis

Blood Culture Result: No growth (from hemodialysis and admission); PICC tip: No growth

Ophthalmologic Exam (Day 5): Consistent with Candida chorioretinitis

Decision Making Based on T2Candida Results

The rapid T2Candida result supported to the continuation of antifungal therapy as well as PICC removal while blood cultures remained negative. The finding of chorioretinitis confirmed a diagnosis of deep-seated infection due to hematogenously disseminated candidiasis and justified both the switch from micafungin to fluconazole after 2 weeks and the total duration of therapy of 6 weeks.

 

1. Clancy, Cornelius J., and M. Hong Nguyen. "Diagnosing candidemia with the T2Candida panel: an instructive case of septic shock in which blood cultures were negative." Diagnostic microbiology and infectious disease 93.1 (2019): 54-57.

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  • According to the CDC, of the 154 million prescriptions for antibiotics written in doctors' offices and emergency departments each year, 30% are unnecessary.12