38 ‘The enemy within’: Candidemia in the immediate postoperative period of complicated appendicitis

Introduction Nosocomial infections complicate 5–10% of hospital admissions in developed countries. Among these, Candida infections have seen a significant increase in incidence, with an impact on morbi-mortality. This is partly due to the rise in patients treated in intensive care units, immunocompromised, or those with venous access devices. Surgical patients can be especially susceptible to these infections, and prevention strategies are key. Clinical Case 62-year-old male with a history of paranoid schizophrenia, chronic hepatitis C (currently inactive), and congenital megacolon that required surgery during his childhood. He presented to the emergency room with a 4-day history of abdominal pain associated with nausea. CT imaging described acute perforated appendicitis, and he underwent laparoscopic appendectomy, which revealed a retrocecal perforated appendix with purulent peritonitis in the right hemiabdomen. A thorough lavage was performed, and microbiological cultures were taken. In the immediate postoperative period, the patient developed an ileus and required the placement of a nasogastric tube and total parenteral nutrition (TPN), which was maintained for 8 days. He received 4 days of treatment with Piperacillin-Tazobactam, later de-escalated to Amoxicillin-Clavulanate according to culture results and antibiogram (E. coli and Streptococcus constellatus). The postoperative course was slow; on the 12th postoperative day, coinciding with the discontinuation of TPN, the patient developed a febrile episode (38.3°C) secondary to thrombophlebitis in the right upper limb where a venous catheter had been placed, and had just been removed the previous day due to extravasation. As part of investigations for the source of fever, blood cultures were taken and ended up being positive for Candida albicans. The infectious diseases stewardship team were involved in the case and empirical treatment with Caspofungin was started for 24 h until susceptibility results were available. To prevent long-term complications of candidemia, the patient was screened for ocular and cardiac diseases with a fundus examination and transthoracic echocardiogram (TTE), respectively. Endocarditis was ruled out, but the fundus exam revealed small chorioretinal lesions consistent with Candida infection, requiring follow-up and treatment. The antifungal therapy was later switched to Fluconazole (with a better ocular penetration) administered intravenously for the first three days. After the control blood cultures were sterile, the patient was discharged and continued outpatient treatment. Educational highlights Any patient with an infection, even if initially controlled, can develop a nosocomial infection. To try to avoid this, it is important to respect prevention strategies, remove unnecessary devices as early as possible and discontinue TPN when feasible. In this case, TPN could have been stopped earlier, yet it was continued for two additional days, thereby contributing to an increased risk of nosocomial infection. Another important issue in patients with candidemia is the performance of a fundus examination, as ocular involvement has been reported in 16% of patients with candidemia. The systematic use of TTE is more controversial, given the low incidence of Candida endocarditis in patients without a prosthetic valve. The main learning point from this case is to pay attention to avoidable infectious complications that can increase morbi-mortality of our patients.