When candida turns deadly

March 01, 2002

By Stephnee Randolph, RN, BSN, PHN

RN/MCPHU Home Study Program
CE CENTER

When candida turns deadly

CE credit is no longer available for this article. (Expired March 2004)

Originally posted March 2002

When candida turns deadly

STEPHNEE RANDOLPH, RN, BSN, PHN

Stephnee Randolph is a continuing education provider in Las Vegas.

KEY WORDS: Candida albicans, candidiasis, immunosuppression, septicemia

Thrush, diaper rash, and vaginal yeast infection are all common manifestations of candida. But for the immunocompromised patient, this common fungal species can cause a host of problems, including life-threatening infections.

Clarisse Martin, 49, was responding well to treatment for systemic lupus erythematosus (SLE). For the first time in months, the arthritic component of her autoimmune disease was under control and she could once again care for herself, take walks, and play the piano. The thrush in her mouth had begun to abate and she was able to eat normal food. She was even gaining weight.
But her reprieve wouldn't last. Within a few months, she developed blurred vision. A visit to the ophthalmologist yielded an unexpected diagnosis: Ms. Martin had ocular candidiasis.
The microbe responsible for Ms. Martin's eye infection was Candida albicans—the most frequent agent of candidiasis and the same common fungus that had caused the sores in her mouth. Candida was once primarily associated with diaper rash in infants and localized skin infections. Today it is recognized as the most common cause of opportunistic infection in immunosuppressed people.¹
In Ms. Martin's case, candida started as thrush, or oral candidiasis. This condition can be treated fairly easily by using antifungal lozenges and mouthwashes; but if the fungus invades the bloodstream through the irritated tissues of the mouth, it can travel to, and cause infection in, other parts of the body. In fact, systemic candidiasis can lead to such disparate conditions as renal failure, respiratory distress, or, in Ms. Martin's case, partial blindness.

The many faces of candidal infection

To understand how a seemingly mild mouth infection could lead to such disastrous consequences, let's take a closer look at the offending microbe. Candidal organisms are opportunistic. They normally live on our skin and mucous membranes, usually causing no harm because they're kept in check by the intact skin and by chemicals secreted from other microorganisms residing on the body's surfaces.
As part of our normal flora, candida can actually protect us from other pathogenic organisms. But when immune function is suppressed, as it was in Ms. Martin, candidal organisms can increase to numbers sufficient to cause infection.
Conditions that support the development of opportunistic infections like candidiasis are inherited or acquired immune system dysfunctions, such as AIDS; autoimmune diseases like SLE, scleroderma, and rheumatoid arthritis; and immunosuppression caused by long-term radiation therapy, cancer chemotherapy, corticosteroid therapy, or drugs used to prevent the rejection of transplanted organs.
Even in people without serious immune dysfunction, candida can cause skin, nail, and vaginal problems. For example, vaginal yeast infections are fairly common, especially in women who are pregnant, have diabetes mellitus, or take oral contraceptives or antibiotics.
Skin candidiasis is also common and occurs particularly in infants, debilitated adults, obese patients, and those with moist surgical dressings. The rash appears red, inflamed, and pustular, and is sometimes covered by a thin veil of whitish exudate. It develops most frequently in the skinfolds and other moist areas of the body—under the breasts or the arms, in the groin, or in the webs of the fingers or toes. Nails infected by candida appear swollen and either red or dark.
Unlike candida of the skin, nails, or vagina, oral candidiasis in an adult is a signal that the immune system is suppressed to the point that an opportunistic infection can take hold.²
The fungus appears as flat, irregular, sticky white patches that adhere tenaciously to the tongue, the gums, or the inside of the mouth. The sores may weep or become painful when the patient eats or drinks, and brushing the teeth can cause the infected gums to bleed. Untreated lesions can progress to deep oral ulcers and can extend into the pharyngeal tissues, causing anorexia, nutritional problems, and dehydration.

Recognizing signs of serious candidiasis

In the immunosuppressed patient, candidiasis can become so severe that it's life-threatening. Such infections can take the following forms:
• Candida septicemia, a potentially fatal systemic infection of the bloodstream, can cause chills, fever, and shock, including reduced urine output and renal failure. The infection develops most frequently in patients who have an indwelling vascular device, such as a central catheter, for long-term drug therapy.^1,3 Fungal plaques collect along the lining of the catheter, from which they can break off and become emboli, traveling to and lodging in other organs or body sites. Candida septicemia can develop in patients with short-term vascular access devices as well.
Over the last two decades, fungal pathogens have accounted for an increasing proportion of nosocomial bloodstream infections in hospitalized patients, and many of these infections were in patients with central catheters.^3,4 Possible sources of the infections? The patients' endogenous flora, contaminated IV fluids and equipment, and the colonized hands of healthcare workers.⁴
• Candida endocarditis starts with fever, heart murmur, splenomegaly, and anemia. Large masses of the fungus collect in major vessels, blocking circulation and potentially leading to embolization.
• Esophageal candidiasis develops when candida from the mouth extends farther into the GI tract. Like oral thrush, the sores make eating painful, which can lead to anorexia and malnutrition. If the infection spreads to the bowel, it can cause abdominal distress, bloating, ulceration, and even perforation.
• Candida meningitis, inflammation of the brain lining (meninges), is not usually fatal but can be chronic. Depending on the extent of a patient's immunosuppression, however, the fungus can invade the brain tissue itself, causing encephalitis, a potentially life-threatening condition that requires parenteral antifungal treatment.
• Candida pyelonephritis, or inflammation of the kidneys, is most likely to occur in patients with long-standing, indwelling urinary catheters. In fact, candida is a major cause of urinary tract infections in hospitalized patients.^2,5Candidal organisms from the skin and perianal tissues travel up the catheter to the bladder, ureters, and kidneys, where they can cause infection. Antifungal medications instilled into the bladder may help prevent progression of the disease to the kidneys.
• Pulmonary candidiasis develops when oropharyngeal infection spreads to the lungs or when fungal emboli infiltrate the lung tissue. Signs and symptoms of pulmonary infection include difficulty breathing, increasing fatigue, and persistent cough. Fever may not be present in patients with markedly depressed immune function, the group in which pulmonary candidiasis is likely to occur.

The importance of controlling candida

Patient management varies according to the site and severity of the infection and the patient's overall condition. Candidiasis of the skin usually responds to antifungal creams. Infected nail beds can be treated with topical amphotericin B (Fungizone). Mouth lesions are managed with oral nystatin (Mycostatin, Nilstat), clotrimazole (Mycelex troche), fluconazole (Diflucan), or amphotericin B solution, administered as lozenges, mouthwashes, or tablets. When oral candidiasis persists, PO ketoconazole (Nizoral) can be used to treat or prevent progression of the lesions to the esophagus. Itraconazole (Sporanox) is also indicated for oropharyngeal and esophageal candidiasis.
The medications that treat serious and systemic candidal infection are listed in the "Treating systemic candidiasis in the immunosuppressed" table, along with select nursing considerations, side effects, and potential drug interactions. Systemic candidiasis usually requires hospitalization for intravenous or intrathecal drug administration, constant monitoring of laboratory test results, and nursing assessments aimed at identifying adverse drug effects, treatment complications, and extension of the infection to other sites.
For treating systemic fungal infections, the gold standard is amphotericin B desoxycholate (Fungizone Intravenous).^1,6,7 It's highly effective but very toxic, particularly to the kidneys. Patients may need to be premedicated with antipyretics, antihistamines, steroids, and/or antiemetic drugs to reduce side effects such as fever and rashes. Studies have shown that the newer, lipid-based formulations of the drug—such as amphotericin B lipid complex (Abelcet) or amphotericin B liposome (AmBisome)—are similarly effective but less toxic, and are used in patients who are refractory to amphotericin B desoxycholate, who have renal impairment, or in whom toxicity is a problem. Flucytosine (Ancobon) is also indicated for systemic fungal infection.
Ms. Martin's ocular candidiasis was treated with oral fluconazole, which worked well at first. When the infection recurred, however, it no longer responded to the drug; her vision continued to deteriorate. Unfortunately, Ms. Martin's immune system was already too depressed to withstand treatment with the more potent amphotericin B. She eventually died of systemic candidal infection.
Whether or not an immunocompromised person will develop—and possibly succumb to—an opportunistic infection like candidiasis depends on a number of factors. In addition to the patient's severity of illness, factors such as illicit drug use, alcohol abuse, poor nutrition, dehydration, infection, and physical and emotional stress can all adversely affect an already compromised immune system.
When caring for immunosuppressed patients, encourage them to eliminate or minimize lifestyle factors that could have a negative impact on their health. Teach them how to properly care for themselves, eat well, balance activity and rest, reduce stress, and manage their time realistically. Taking these and other steps to protect and preserve their immune function may help keep a minor candidal infection from becoming a deadly one.

REFERENCES

1. Beers, M. H., & Berkow, R. (Eds.). (1999). The Merck manual of diagnosis and therapy (17th ed.). Whitehouse Station, NJ: Merck & Co.
2. Rakel, R., & Kersey, R. (Eds.). (2000). Saunders manual of medical practice (2nd ed.). St. Louis, MO: W. B. Saunders.
3. Kontoyiannis, D. (2001). A clinical perspective for the management of invasive fungal infections: Focus on IDSA guidelines. Pharmacotherapy, 21(suppl 8), 175S.
4. Pearson, M. L., & Hospital Infection Control Practices Advisory Committee. "Guidelines for prevention of intravascular device-related infections." 2001. www.cdc.gov/ncidod/hip/IV/Iv.htm (17 Nov. 2001).
5. Wong, E. S., & Hooten, T. M. "Guideline for prevention of catheter-associated urinary tract infections." 2001. www.cdc.gov/ncidod/hip/guide/uritract.htm (17 Nov. 2001).
6. Arikan, S., & Rex, J. H. (2001). Lipid-based antifungal agents: Current status. Curr Pharm Des, 7(5), 393.
7. Doyle, R., & Johnson, P. (Eds.). (2001). Nursing 2000 drug handbook, (22nd ed.). Springhouse, PA: Springhouse.

Treating systemic candidiasis in the immunosuppressed

Candidal organisms are opportunistic. When immune function is suppressed, they can increase to numbers sufficient to cause serious or systemic infections. This table lists the agents most commonly used for systemic candidiasis.

Drug name/Use	Key side effects*	Drug interactions	Select nursing considerations
Amphotericin B desoxycholate (Fungizone Intravenous); amphotericin B lipid complex (Abelcet); amphotericin B liposome (AmBisome) Uses: Systemic candidiasis	Renal toxicity, hypokalemia, impaired hepatic function, thrombocytopenia, anaphylaxis, chills, fever, tinnitus, headache, GI disturbances, vomiting, thrombophlebitis, others. Neurotoxicity may occur when given intrathecally. Newer, lipid-based preparations are less toxic.	Enhances effect of flucytosine (Ancobon) and antibiotics, increasing toxicity. Don’t give concomitantly with steroids. Also interacts with ketoconazole (Nizoral), miconazole (Monistat), aminoglycosides, thiazides, skeletal muscle relaxants, antineoplastics, and zidovudine (Retrovir)	Give IV form in D₅W; do not mix with normal saline, electrolytes, or other drugs; infuse slowly, according to product labeling; protect from light. Premedicate as ordered to reduce side effects. Test dose may be indicated. Monitor vital signs every 15 minutes during first dose. Monitor labs, especially BUN, serum creatinine and potassium, and platelet count. Abelcet and AmBisome are indicated for patients who are refractory to amphotericin B desoxycholate, who have renal impairment, or in whom toxicity is a problem.
Fluconazole (Diflucan) Uses: Oropharyngeal, esophageal, and disseminated candidiasis; systemic candidal infection, candidal pneumonia, and candidemia; prophylaxis in bone marrow transplant patients receiving chemotherapy or radiation	Nausea, headache, abdominal pain. Less common: exfoliative skin lesions, including Stevens-Johnson syndrome. Rare: hepatitis	Interacts with oral hypoglycemic drugs, anticoagulants, phenytoin (Dilantin), rifampin (Rifadin, Rimactane), rifampin/isoniazid (Rifamate), cyclosporine (Sandimmune), and theophylline	May be ordered PO or IV. Shake the oral suspension well before administering. Administer IV solution at a maximum rate of 200 mg/hr. Monitor liver function. HIV infection may increase the risk of side effects.
Flucytosine (Ancobon) Uses: Candidal septicemia, urinary tract infection, endocarditis, or pulmonary infection	GI disturbances (nausea, vomiting, anorexia), rash, urticaria. Rare: exfoliative skin conditions, fulminant hepatic necrosis, aplastic anemia, agranulocytosis, and other blood dyscrasias. Renal impairment is also possible.	Synergistic with amphotericin B but toxicity increases when the two are given together	Give capsules a few at a time over 15 minutes to minimize nausea and vomiting. Monitor blood count and renal and hepatic function. Used with amphotericin B for severe infections. Use with caution in patients with kidney or liver disease and in those previously treated with radiation or chemotherapy.
Ketoconazole (Nizoral) Uses: Systemic candidiasis	Nausea, vomiting, abdominal pain, pruritus. Rare: liver toxicity	Decreased absorption when given with rifampin, antacids, or H₂-blockers. Interacts with cyclosporine, raising concentrations of either or both drugs. Use cautiously in patients taking anticoagulants, antiseizure medication, miconazole, or oral hypoglycemics	Given orally. Requires acidic environment for absorption, so don’t give within 2 hrs of antacids or other drugs that increase gastric pH. Monitor liver function. May be a good choice for patients with kidney disease because the drug is broken down in the liver and excreted in the feces

*Listed in order of more to less frequent.
Sources: 1. Rang, H. P., Dale, M. M., et al. (2001). Pharmacology. New York: Churchill Livingstone. 2. Physicians' desk reference (55th ed.). (2001). Montvale, NJ: Medical Economics. 3. PDR nurse's drug handbook. (2001). Montvale, NJ: Medical Economics.

Stephnee Randolph. When candida turns deadly. RN 2002;3:41.

Published in RN Magazine.

Stephnee Randolph, RN, BSN, PHN

Stephnee Randolph is a continuing education provider in Las Vegas.

my mess/ms

Friday, 29 July 2016

Killer Candida