4CPS-079 Patient with complicated fungal endocarditis: a case report. (March 2019) - Bellegarde, J
Abstract : Background: Fungal endocarditis is the most serious form of infective endocarditis. It is associated with high morbidity and mortality. In 2016, the Infectious Diseases Society of America (IDSA) updated Clinical Practice Guidelines for the Management of Candidiasis that strengthens the use of echinocandins for candidiasis' initial therapy. Purpose: We report here a case of a nosocomial fungal endocarditis treated with echinocandins in the Intensive Care Unit (ICU). Material and methods: A 53-year-old woman was hospitalised for multiple traumas after a car accident. Her anti-infective treatment was collegially decided after multidisciplinary discussions. In addition, the local fongemia ecology was regularly followed since 2014 and pharmacists document each patient's treatment. Results: On 27 June 2018 the patient who had no significant medical history was admitted to the ICU. On 4 July a Candida albicans fungemia was diagnosed: a probabilistic treatment with caspofungin 70 mg daily was introduced and all intravenous devices were removed. The daily dose was increased to 140 mg on 11 July according to the new IDSA guidelines after documentation of endocarditis. A surgical treatment was refuted because of the risk of bleeding and haemodynamic context of the patient. Six fungal blood cultures returned positive under caspofungin treatment, despite the C.albicans susceptibility to caspofungin. On 14 July additional blood cultures returned positive to C.glabrata with a caspofungin intermediate susceptibility (MIC 0.125). Caspofungin was therefore discontinued and switched for Lipid Formulation AmB (LFAmB) (the two Candida strains were susceptible) and flucytosine. This association was continued for 8 weeks after the first negative blood culture, 4 days after the switch to LFAmB. Conclusion: The patient's infection was successfully managed thanks to the good collaboration between physicians, infectious diseases specialists, microbiologists and pharmacists, which represents a key element of an antimicrobial stewardship plan. 1 Transition to fluconazole was considered in the light of C.albicans fluconazole-susceptibility consistent with our local ecology (100% of C.albicans strains susceptible to fluconazole). This case underlines the need for keeping in mind the importance of documentation isolates sensitivity, particularly with the increasing resistance of Candida spp to echinocandins, 1 and adapting the treatment according to the local fungal ecology. Reference and/or acknowledgements: Perlin DS, et al. Lancet Infect Dis 2017;17:e383–e392. https://www.sciencedirect.com/science/article/pii/S147330991730316X?via%3Dihub No conflict of interest.