History and exam
Key diagnostic factors
common
fever
One of the most common symptoms seen with this condition. If sepsis is present, temperature may be >101°F (>38.3°C).
Other diagnostic factors
common
tachycardia
If sepsis is present, heart rate may be >90 bpm.
tachypnea
If pneumonia and sepsis is present, respiratory rate may be >20 breaths/minute.
hypotension
Hypotension that persists for at least 1 hour, and in spite of adequate fluid resuscitation, is a sign of septic shock.
Correction of hypotension with vasopressor agents does not exclude shock.
poor capillary refill
Cold, clammy skin is also a sign of hypoperfusion in sepsis.
acute mental confusion
Sign of hypoperfusion and sepsis.
decreased urine output
Sustained oliguria in spite of adequate volume infusion or resuscitation is a sign of hypoperfusion and sepsis.
low oxygen saturation
Sign of sepsis.
uncommon
rash
Can be maculopapular to nodular, often erythematous; usually neutropenic patients.
hepatosplenomegaly
May be seen in patients with chronic disseminated candidiasis, which usually involves the liver and spleen, and can be seen in patients recovering from neutropenia (often prolonged).
hypothermia
If sepsis is present, temperature may be <96.8°F (<36°C).
Risk factors
strong
use of central venous catheter
This is one of the most important risks for systemic candidiasis. Intravascular catheters (especially central venous catheters, including those for dialysis) present a ready portal for the yeast to gain entry to the bloodstream, and from there, to the rest of the body.
exposure to broad-spectrum antibiotics
This is critical to the alteration of normal flora, which allows Candida to overgrow. This makes it more likely to cause invasive disease when the opportunity is available (i.e., presence of intravascular catheters, mucosal disruption). The broader the spectrum of antibiotic, the higher the risk.
renal dialysis
This risk is primarily due to the large, central vascular access catheters used, and the prolonged length of time they are required. Peritoneal dialysis catheter can also result in peritoneal candidiasis, especially in the setting of antibiotic therapy for bacterial catheter-associated peritonitis.
surgery
Any mucosal break that occurs can be a conduit for invasion by Candida, particularly during gastrointestinal surgery. Intra-abdominal candidiasis without associated candidemia is the most common presentation of invasive candidiasis in this setting and is frequently polymicrobial with bacterial pathogens.
parenteral nutrition
Much of this risk is due to the prolonged presence of central venous catheters.
use of immunosuppressants
In addition to the direct immunosuppressive effects of corticosteroids and other immunosuppressants (including biologics) and neutropenia from chemotherapeutic agents, chemotherapy may also lead to gut mucosal injury and disruption.
Graft versus host disease following stem cell transplantation can also play a role through gut and/or skin injury as well as exposure to additional immunosuppressive therapies to treat the condition.
weak
colonization at multiple sites
The greater the burden of Candida in a patient, the higher the likelihood of tissue invasion when epithelial barriers are broken.
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