Candidemia Requires Routine Ophthalmologic Evaluation!
Treatment Day 4: Ophthalmological Findings

Medical History
Age: 72 year-old Sex: Male Weight: 60 kg Ulcerative colitis. Total gastrectomy, splenectomy, and cholecystectomy for gastriccancerPostoperative Course
Postoperative day 4: esophagojejunostomy anastomotic leakage occurred, and fasting management was performed.

Diagnosis of ocular candidiasis (both eyes, particularly the right eye)Right eye: subjective symptom of vitiligo within 1 disc diameter of macula and “black flickering in
the right eye”
Left eye: light vitiligo in arcade

Postoperative day 15: a central venous catheter was inserted and nutritional management was started. Postoperative day 24:
pyrexia of 39.8 °C was noted and 2 sets of blood cultures were collected. Postoperative day 4 (day 1 of treatment): detection ofyeast-like fungi from blood culture, initiation of caspofungin (CPFG), removal of central venous catheter due to candidemia fromcentral venous catheter＜Day 1 of Treatment Physical Examination＞
Body temperature: 39.5 °C, blood pressure: 93/52 mmHg, pulse: 98 beats/min, WBC: 18600/μL, Plt: 188000/μL, T-Bil: 0.4 mg/dL,
AST: 32 U/L, ALT: 31 U/L, CRP: 12.3 mg/dL, eGFR: 60 mL/min/1.73 m2, β-D glucan: 100.5 pg/mL

Course of Treatment
Treatment day 2: two sets of blood cultures were taken to confirm negative blood cultures. Treatment day 4: yeast-like fungus
detected in the blood culture was identified as C. albicans, and patient presented subjective symptoms of "black matter flickeringin the right eye." Eye lesion was diagnosed by ophthalmic examination, CPFG was discontinued, and switched to amphotericin B
ribosome preparation (L-AMB) and flucytosine (5-FC). Treatment day 10: improvements in subjective symptoms in the right eye.
Treatment day 16: improvements seen in fundus findings from ophthalmic examination. Treatment day 29: although fungal massin the fundus oculi remained during the ophthalmologic examination, diagnosed as suitable for oral drugs and fluconazole (FLCZ)
was substituted. Treatment day 44: the patient was discharged from the hospital (oral administration of FLCZ was continued).
Treatment day 72: treatment was discontinued due to improvement in findings of ocular fundus during an outpatient
ophthalmologic examination.

Lesions near the macula are associated with visual abnormalities.
Lesions extending beyond the retinochoroid membrane into vitreous humor (vitreousinfiltration) may decrease vision.

Points for diagnosis and treatment of ocular lesions in candidemia
Diagnosis: the incidence of ocular lesions in candidemia ranged from 12.8% to 19.5%, and progressive lesions
such as vitreous infiltration were found in approximately 40% of cases of ocular lesions in a nationwide surveyin Japan ⇒ candidemia requires routine ophthalmologic examinations
Treatment: choice of antifungal drug byocular migration

Ocular migration for each systemicallyadministered antifungal agent
Blood
Concentration(μg/ml)Intravitreal
Concentration(μg/ml)Amphotericin B

0.6～1.5

0.10～0.23

Flucytosine

10～35

22.2

Candice fungus-type（micafungin and caspofungin) :Fluconazole

17.4

12.1

Not recommended for treating eye lesions due topoor ocular migration.

Voriconazole

2.13

0.81

Micafungin

21.02

0.1

Discuss surgical indications with an ophthalmologist.

Caspofungin

4.7-Amphotericin B :Low ocular migration but treatment outcomes good insevere cases such as vitreous infiltration. Currently,
liposomal amphotericin B is recommended, which hasfewer side effects.

Treatment duration: 2 weeks after negative blood culture for candidemia without disseminated disease. Treatment ofocular candidiasis is continued for at least 4 ~ 6 weeks with regular ophthalmologic examinations until the lesion has healed.
In particular, it is recommended to check with an ophthalmologist during the treatment period because the treatment isprolonged in cases of vitreous infiltration.
Antimicrobial resistance problem: Since increasing the use of candin antifungal drugs leads to more candidin-resistantCandida spp, it is necessary to select an appropriate antifungal drug that considers tissue penetration.
AMR Alliance Japan requested this case report as a part of a project to compile examples of antimicrobial stewardship and cases with and without the use of antibiotics.
For more information, please contact AMR Alliance Japan. Grand Cube, 3rd Floor, 1 -9 -2 Otemachi Financial City, Otemachi, Chiyoda-ku, Tokyo 100 0004 Tel: 03-4243-7156 Fax: 03-4243-7378 E-mail: info@hgpi.org