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Case report |
Departments of 1 Microbiology and 2 Diagnostic Imaging, Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK
Correspondence: Dr Andrea Guyot, Consultant Microbiologist, Department of Microbiology, Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK. E-mail: andrea.guyot{at}royalsurrey.nhs.uk
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Abstract |
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Introduction |
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Day 1 post-operatively, the patient developed central venous catheter (CVC) infection and Candida glabrata was grown from blood cultures taken through the CVC, peripheral line and later from the CVC tip. He commenced treatment with Liposomal Amphotericin B (AmBisome). The CVC in his external jugular vein was removed and resisted in his left femoral vein because central venous access was crucial as he was critically ill, needing inotropic support. He continued to have candidaemia and 7 days later his left leg was noted to be swollen. Doppler scan of his femoral veins revealed bilateral deep vein thrombosis. He was started on heparin and the femoral line was removed. The next day, he had a Gunther Tulip retrievable inferior vena cava (IVC) filter (William Cook Europe, Bjaeverskov, Denmark) placed in his inferior vena cava via the transjugular route as prophylaxis against pulmonary embolism (PE).
Despite Amphotericin therapy for 10 days, he continued to have a high temperature, with elevated white blood cell (WBC) and C-reactive protein (CRP), and C. glabrata was resited from his blood cultures persistently. The IVC filter was considered for removal but this was outweighed by the high risk of PE. Amphotericin was changed to Caspofungin because of its superior efficacy of penetrating into biofilms [1, 2]. He remained candidaemic with a high temperature and raised inflammatory markers after 48 h of Caspofungin at which stage the IVC filter was removed (15 days after its insertion) following consultation with vascular surgeons who judged that the thrombus was now sufficiently organized for removal of the IVC filter.
Direct cultures of the IVC filter on Sabaraud dextrose agar plates were negative. The filter was placed in Robertson's cooked meat broth (RCMB) for enrichment from which C. glabrata was isolated.
He remained apyrexial after removal of the IVC filter, his WBC and CRP remained normal, and his blood cultures were sterile. He was discharged out of ITU to the wards to complete a 6-week course of Caspofungin for septic central vein thrombosis.
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Discussion |
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The risk factors for the development of candidaemia include: prolonged ITU stay, use of CVC and other prosthetic devices, total parenteral nutrition, prior use of antibiotics and immunosupression.
Candidaemia and thrombosis are well known complications following central venous catheterization. However, septic candida thrombophlebitis of the central veins is less frequent and probably an underreported complication of central venous catheterization [3].
Septic thrombophlebitis of the deep veins is a life-threatening complication following central venous catheterization. The risk of CVC related DVT is approximately 10% and the risk of catheter related sepsis increases by 2.6 times when thrombosis occurs [4].
Causative organisms for septic thrombophlebitis include Staphylococcus aureus, Staphylococcus epidermidis, Gram negative organisms such as Klebsiella, Pseudomonas and Enterobacter species and Candida.
A literature search of cases of candida thrombophlebitis and candida inferior vena caval filter infections over the last 25 years revealed 18 reported cases of candida thrombophlebitis and no cases of candida IVC filter infection [3, 5].
Among the cases of candida thrombophlebitis reported C. albicans was the most common causative agent and the other species reported has been C. glabrata. Thrombosis occurred more frequently in the superior vena cava/subclavian/right atrium and less commonly in the inferior vena cava, which could probably be explained by the fact that the upper extremity veins are more frequently catheterized than lower extremity veins. The most common presentation was fever with or without oedema. The risk factors associated with the development of candida thrombophlebitis were presence of CVC, antibiotic treatment, admission to ITU and abdominal surgery. All cases were treated with Amphotericin B with or without surgery (excision of the affected veins). Mortality attributable to candida thrombophlebitis was 22%.
To the best of our knowledge this is the first case report of candida IVC filter infection. Although it is known historically that foreign material placed in tissues tend to form biofilms, our case report emphasizes this and the fact that it is important to remove such material when clinically indicated (recurrent bacteraemia/candidaemia, worsening clinical condition, risk-benefit assessment). The filter that was placed in the IVC of our patient was a retrievable Gunther Tulip IVC filter, which could be removed promptly via the transjugular route when the risk of development of PE was reduced. The ideal time for removal of these filters is within 10–14 days following insertion. After this time there is an increased risk of IVC tear during removal because of incorporation of the filter into the caval wall, although recent reports describe safe and successful removal of the filter after 14 days [6].
Direct culture of the IVC filter on Sabouroud dextrose agar plates yielded no growth; whereas subculture from RCMB grew C. glabrata. This needs to be considered while processing prosthetic devices in laboratories.
Caspofungin, the newer antifungal agent, has not been reported to have been used for the treatment of central venous Candida thrombophlebitis. Successful treatment of our patient with Caspofungin suggests that this drug can be effective in candidal intravascular infections.
Received for publication December 15, 2005. Revision received March 15, 2006. Accepted for publication March 16, 2006.
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