Popovich, Kyle MD*; Malani, Preeti N. MD*†‡+§; Kauffman, Carol A. MD*‡; Cinti, Sandro K. MD*‡
*Divisions of Infectious Diseases and †Geriatric Medicine, Department of Internal Medicine, ‡Veterans Affairs Ann Arbor Healthcare System and §Geriatric Research Education and Clinical Center, University of Michigan Health System, Ann Arbor, MI.
Address correspondence and reprint requests to Sandro K. Cinti, MD, Ann Arbor Veterans Affairs Healthcare System, 2215 Fuller Road, 111-I, 8th Floor, Ann Arbor, MI 48105. E-mail: firstname.lastname@example.org.
Background: Although ophthalmologic examination is recommended for patients with candidemia, the rate of compliance with this recommendation is unknown.
Method: We reviewed records for 100 consecutive adult patients who had candidemia.
Results: Candida albicans was the pathogen in 55. Among the 80 patients who had an eye examination, 3 had endophthalmitis, and 2 had chorioretinitis. One of the 20 patients who had no examination later presented with endophthalmitis. Among 74 patients for whom an infectious diseases consultation was obtained, 66 (89%) had an ophthalmology consultation compared with 14 (54%) of 26 patients for whom an infectious diseases consultation was not obtained (P < 0.001).
Conclusion: Infectious diseases consultation improves adherence to suggested guidelines for the evaluation of candidemia.
Candida species are the fourth leading cause of nosocomial bloodstream infections,1 and an increasing proportion of candidemias are due to non-albicans isolates, in particular Candida glabrata.2-4 Endophthalmitis, a major complication of candidemia, is defined as chorioretinitis with extension into the vitreous (vitritis).2 The incidence of ocular involvement in prior studies has varied from 4% to 28%.4,5 Delays in the diagnosis of Candida ocular infection can lead to loss of vision.6 The identification of ocular involvement has therapeutic implications, impacting both the choice of antifungal agent and the duration of treatment.7
The 2004 Infectious Diseases Society of America (IDSA) guidelines recommend that all patients with candidemia undergo at least 1 dilated retinal examination performed by an ophthalmologist, preferably at a time when candidemia seems controlled and new spread to the eye is unlikely.6 We sought to determine physician compliance with IDSA guidelines for ophthalmologic evaluation of endophthalmitis/chorioretinitis in patients with candidemia.
PATIENTS AND METHODS
A retrospective review of the medical records for all patients 18 years and older who had candidemia seen between January 1, 2003, and December 31, 2005 at the University of Michigan Health System, a 650-bed tertiary care medical center, was performed. This study was approved by the University of Michigan Institutional Review Board.
Because patients who died within 48 hours of admission were unlikely to be examined by an ophthalmologist, these patients were excluded. End points of interest were whether an infectious disease consultation was obtained, completion of a dilated ophthalmologic examination, results of the examination, 1- and 3-month outcomes, and Candida species causing candidemia.
A total of 100 adult patients with candidemia within the study period were identified. Fifty-one patients (51%) were men. The mean age was 50.3 ± 16.4 years (range, 18-82 years). A total of 64 patients were on a medical service, 34 were on a surgical service, and 1 each was on the neurological and gynecological services. Candidemia was most commonly caused by Candida albicans (55%), followed by C. glabrata (27%) and Candida parapsilosis (11%) (Table 1).
Infectious diseases consultation was obtained for 74 patients: 72% (46/64) of patients with candidemia on the medical service, 77% (26/34) of patients with candidemia on the surgical service, and both patients on other services. An ophthalmology consultation was obtained on 80 patients. Of the 74 patients seen by the Infectious Diseases consult team, 66 (89%) had an ophthalmology consultation compared with 14 (54%) of 26 patients for whom an infectious diseases consultation was not obtained (P < 0.001).
Of the 80 patients who underwent a dilated ophthalmologic examination, 5 (6%) had evidence of ocular involvement, 3 with endophthalmitis, and 2 with chorioretinitis. The 3 patients with endophthalmitis had experienced candidemia due to C. albicans, whereas the 2 patients with chorioretinitis had candidemia due to C. parapsilosis and C. glabrata. At 3 months, of these 5 patients, 2 had died within 1 month while still in the intensive care unit, 1 on fluconazole, and 1 on liposomal amphotericin B therapy; the outcome of the ocular disease was not noted. One patient, a liver transplant recipient, developed blindness from bilateral C. albicans endophthalmitis, despite treatment with fluconazole and intravitreal injections with amphotericin B. The remaining 2 patients-1 with chorioretinitis and 1 with endophthalmitis-were treated with fluconazole and had complete resolution of visual symptoms. None of the 80 patients who had undergone an eye examination later developed signs of Candida eye infection.
Among the 20 patients who did not receive an ophthalmologic evaluation, 1 patient (5%) who had C. glabrata candidemia presented 1 month later with endophthalmitis. This patient was treated successfully with caspofungin and had no visual loss. At 1 month after the episode of candidemia, 16 (84%) of the 19 remaining patients were alive with no ocular complaints, 2 (11%) had died, and 1 (5%) was discharged to hospice. At 3 months, 13 (68%) remained alive with no ocular symptoms, 3 (16%) had died, and 3 (16%) were lost to follow-up.
Endophthalmitis remains a serious complication of candidemia.8-10 Without adequate treatment, this frequently results in loss of vision. In our study of 100 patients who had candidemia, 80 (80%) received a dilated ophthalmologic examination as recommended by the IDSA guidelines. Patients seen by the infectious diseases consult service were significantly more likely to undergo an ophthalmologic examination than those patients who did not receive a formal infectious diseases consult. Infectious diseases consultation has been shown to improve compliance with IDSA guidelines and, in at least 1 study, was associated with improved survival from candidemia.11 In a study of patients who had cryptococcal meningitis, those whose care followed IDSA guidelines had fewer adverse neurological outcomes.12
The overall incidence of Candida eye involvement was 6%. This rate is similar to the rates noted in the last 2 decades but less than the incidence of eye involvement noted in earlier studies.3,4 Several authors have postulated that early initiation of antifungal therapy in candidemic patients likely helps prevent ocular complications,2,13 and this may explain our low incidence of documented chorioretinitis and endophthalmitis.
It has been suggested that candidemia with non-albicans species may be less likely to lead to eye complications.14 Recently, Malani et al15 noted no cases of eye disease among 103 patients at our medical center who had C. glabrata candidemia from 1995 to 2002. Several other series assessing the causes of endophthalmitis in tertiary care centers failed to demonstrate any cases caused by non-albicans Candida species.16,17 In our study, however, no differences were noted in the predilection to cause ocular involvement among the different species; 1 of 11 patients with C. parapsilosis candidemia and 2 of 27 patients with C. glabrata candidemia developed chorioretinitis or endophthalmitis compared with 3 of 55 patients who had C. albicans candidemia.
Of the 5 patients who were found to have eye involvement when a dilated ophthalmologic examination was performed, 2 had excellent outcomes, 2 died soon after diagnosis, and 1 had persistent blindness. The 1 patient who later presented with C. glabrata endophthalmitis was successfully treated with caspofungin and had no permanent visual loss.
This study documents a lack of adherence to the recommendation of obtaining an eye examination in every patient who has candidemia. It would seem that this is important for all patients with candidemia, not just for those infected with C. albicans. There were too few cases to discover whether a delay in diagnosis in patients who do not have an examination and are later found to have ocular involvement leads to a worse outcome.
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