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Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Candidemia

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In one line

·Candida in the bloodstream is a serious fungal infection that requires immediate antifungal treatment, usually with an echinocandin drug.

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Normal physiology

·Candida is a yeast that normally lives on your skin, in your mouth, and in your intestines without causing harm. Your immune system and the good bacteria in your body keep it under control. Blood is supposed to be completely sterile—no germs, no yeast, nothing living in it. The body has strong barriers (like skin and the gut lining) to keep Candida out of the bloodstream.

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What goes wrong

·Candidemia happens when Candida yeast crosses from the skin or gut into the bloodstream, where it does not belong. This usually requires a combination of broken barriers (like a tube punching through the skin or a leaky gut) and a weakened immune system that cannot kill the yeast fast enough.

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Hallmark signs

·Fever that does not go away even when the person takes antibiotics
·Chills and shaking
·Low blood pressure (the person may feel dizzy or confused)
·Fast heart rate
·Breathing faster than normal
·Confusion or being less alert than usual
·White patches or spots inside the eyes (seen by a doctor looking with a special light)
·Skin bumps or nodules (small lumps under the skin)

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Red flags · escalate now

·Blood pressure drops suddenly (shock), meaning organs may not be getting enough blood
·The person becomes very confused, hard to wake up, or unresponsive
·White spots appear in the eyes (endophthalmitis), which can cause blindness if not treated quickly
·Signs of infection spreading to the heart valves, such as a new heart murmur or worsening heart failure
·Kidneys stop making urine or urine output drops sharply, a sign the kidneys are failing

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Workup

·Blood cultures (two sets from different sites)
·Candida species identification and antifungal susceptibility testing
·Beta-D-glucan blood test
·Dilated ophthalmoscopy (eye exam by an ophthalmologist)
·Echocardiogram (ultrasound of the heart), preferably transesophageal (TEE)
·CT scan of the abdomen and pelvis with IV contrast

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Treatment

·Start an echinocandin antifungal (caspofungin 70 mg loading dose then 50 mg daily, micafungin 100 mg daily, or anidulafungin 200 mg loading then 100 mg daily) immediately when blood culture grows yeast
·Remove or replace all central venous catheters (central lines, PICC lines, dialysis catheters) within 24 to 48 hours
·Ophthalmology exam (dilated fundoscopy) within the first week of diagnosis, repeated weekly if neutropenic or if candidemia lasts more than a few days
·Continue echinocandin for at least 14 days after the last positive blood culture and resolution of symptoms, then consider switching to fluconazole 400 to 800 mg daily if the patient is stable and the Candida species is susceptible
·Image and drain any abscesses (pockets of pus) found in the liver, spleen, kidneys, or other organs, especially if larger than 3 cm
·Stop or narrow unnecessary antibiotics that kill bacteria; restore normal gut bacteria with enteral feeding if possible
·Transthoracic or transesophageal echocardiogram if candidemia lasts more than a few days, a new murmur appears, or the patient has a prosthetic heart valve or pacemaker

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NCLEX trap

·Bacteria antibiotics will never kill candidemia because the invader is a fungus, not a bacteria. You need an antifungal drug — start an echinocandin (like caspofungin or micafungin) right away. Giving more antibiotics is like trying to cut wood with a hammer; it's the wrong tool for the job.
·Start an echinocandin the moment Candida shows up in even one blood culture bottle. Do not wait. Candidemia spreads fast — to the heart valves, the eyes, the brain, and deep organs — while you delay. Start treatment now and adjust later if you need to.
·The central line is the main highway for Candida to keep pouring into the blood. Remove it or replace it in a new spot within 24 hours. If you leave the old line in, candidemia will keep coming back no matter how much antifungal you give. Removing the fungus source comes before keeping the line.
·Always start with an echinocandin (caspofungin or micafungin) for candidemia — it kills faster and works on more types of Candida. Switch to fluconazole only after the patient is stable, getting better, and you know the Candida type is fluconazole-sensitive. Echinocandin is the first choice for sick patients; fluconazole is for stable patients or step-down therapy.
·Candidemia is life-threatening and completely different. It needs a powerful antifungal (echinocandin first), line removal, a heart ultrasound to check the valves, an eye exam within one week to look for retinal infection, imaging to search for abscesses, and at least 14 days of treatment after the blood cultures turn clean. Candida in urine is local and often just needs fluconazole or sometimes no treatment at all if there are no symptoms. Candidemia is systemic and deadly.
·Candidemia can trick you. Fever may go down, but the fungus may already be growing on heart valves, in the eyes, or forming pockets of infection (abscesses) in the belly or liver. You must do a dilated eye exam within one week, get a heart ultrasound (echocardiogram) to check for valve infection (endocarditis), repeat blood cultures to prove the blood is clean, and keep treating for the full course even if the patient looks better.

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