Invasive candidiasis in abdominal sepsis — FFICM MCQ

Correct answer: D — Start an echinocandin and pursue source control

The correct answer is D, start an echinocandin and pursue source control. This patient has proven Candida glabrata candidaemia with septic shock, ongoing intra-abdominal collections, a central venous catheter, and acute kidney injury, all classic risk factors and indications for invasive fungal disease following prolonged broad-spectrum antibiotics and TPN. Echinocandins (caspofungin, anidulafungin, micafungin) are first-line for candidaemia because C. glabrata frequently shows reduced fluconazole susceptibility, and echinocandins retain fungicidal activity without renal dose adjustment concerns, which matters given her AKI. Source control (drainage of collections, removal of the CVC as a likely source) is mandatory alongside antifungal therapy, as persistent collections and infected lines perpetuate fungaemia regardless of drug choice. Why the other options are wrong: B. Start oral fluconazole alone: fluconazole has unreliable activity against C. glabrata and is inappropriate as sole therapy in a haemodynamically unstable, critically ill patient with an unremoved source. E. Ignore Candida as a contaminant: candidaemia is never a contaminant; blood culture growth of Candida always represents true infection requiring treatment. A. Treat with nebulised amphotericin: nebulised antifungals treat pulmonary/airway colonisation, not bloodstream infection, and have no role in systemic candidaemia. C. Stop antibacterial therapy and observe: stopping antibacterials without addressing the fungal infection or the intra-abdominal source would allow ongoing sepsis from both bacterial and fungal pathogens to progress untreated. Key point: Candidaemia with C. glabrata in a critically ill patient mandates prompt echinocandin therapy plus aggressive source control (line removal, drainage), never observation or fluconazole monotherapy.

Reference: Scottish Antimicrobial Prescribing Group, Good Practice Recommendations for Treatment of Candidaemia and Use of Antifungal Agents, 2022 (UK critical care practice), https://www.sapg.scot/media/5442/20220110-gprs-for-treatment-of-candidaemia-and-use-of-antifungal-agents.pdf