Journal of Infectious Diseases & Therapy
Open Access

We reported a case of central venous catheter-related Candida parapsilosis fungemia evolved to disseminated infection with skin and ocular involvement in a neutropenic patient undergoing re-induction chemotherapy because of a recurrence of blast crisis of chronic myeloid leukemia [1]. In this patient, the delay in vascular catheter removal facilitated the spreading of a mild pathogen (C. parapsilosis) which revealed its ability to cause a potentially lethal infection in a deeply immunocompromised host. C. parapsilosis is able to colonize polyurethan devices so we encountered important difficulties in managing the infection due to the need to maintain venous access that guaranteed the patient adequate support in fluids and antimicrobials agents. However, the infection’s source persistence led to a persistent fungemia despite the best antifungal therapy administered with the development of a disseminated infection [1].

CVC related infections outcomes and management in neutropenic onco-hematological patients

Early CVC removal within 3 days has been reported to have a positive effect on early mortality rates in patients with CVC related Candidemia treated with antifungal therapy [2]. More than 80% of cases of Candida infection were documented in patients with acute leukaemia [2]. The attributable mortality rate was 33%. Speciesspecific attributable mortality rate ranged from 6% for infections caused by C. parapsilosis to 54% for those due to C. tropicalis. The underlying hematologic malignancy, severity of immunosuppression, and presence of indwelling devices represent determinant factors for the outcome more than any antifungal therapy [2].

As the retention of the CVC in patients with suspected CVC-related infection can result in treatment failure or recurrence of infection in spite of antibiotic therapy, CVC removal is encouraged in all patients whenever possible [3]. Early CVC removal is particularly indicated in patients with deteriorating clinical state, sepsis or septic shock and in case of severe complications such as endocarditis, septic thrombosis, abscess formation and osteomyelitis. CVC removal is also warranted in case of continued positive blood cultures 72 hours after initiation of therapy in spite of appropriate antimicrobial therapy. CVC retention along with systemic antibiotic treatment may be acceptable in hemodynamically stable patients under careful surveillance and for selected pathogen. Early CVC removal is always recommended in patients with CVC-related infections due to Candida spp. and Staphylococcus aureus [3]. S. aureus is the most prevalent pathogen of Infective Endocarditis (IE); it comprises 60% of cases and is associated with the use of intravascular catheters [4]. Almost 10% of IE occur in hospitalized patients except for patients with valvular replacement; more than 80% of the patients have an endovenous indwelling catheter [4]. S. aureus is more common in nosocomial acquisition than in community acquired infections [4]. Several studies in patients with S.aureus bacteriemia indicate an increased risk for hematogenous complications, relapse of infection and death of infection if the CVC is retained after detection of S. aureus [3]. El Zackhem and colleagues reported a higher rate of relapse in cancer patients whose CVC was retained beyond 3 days compared with those whose CVC was removed or exchanged within the first 3 days from the onset of bacteriemia [3,5]. Enterococcus species are the third most common organisms causing Central Line-Associated Bloodstream Infections (CLABSIs). The management of enterococcal CLABSI,including the need for and timing of catheter removal, is not well defined [6,7]. In a study on the management of Enterococcal central– line associated bloodstream infections in patient with cancer. Awad, et al. showed that patients with Mucosal Barrier Injury (MBI) were more likely to have a higher rate of neutropenia, a significantly higher rate of bacteremia by Vancomycin Resistant Enterococcus (VRE) and a significantly higher mortality rate [7]. Early CVC removal in less than 3 days was associated with a better overall outcome compared to late removal between 3 and 7 days (78% vs. 67%, p=0.003) [7]. IE is a rare occurrence among patients with acute leukemia; the often low platelet count might be a cause for this low frequency [6]. Left-sided IE is an indication for surgical intervention but high rates of complications are related to surgical valve procedures for treatment of IE [4,6].

At our institute there have been 2 cases of infective endocarditis on native mitral valve in neutropenic patients suffering from haematological neoplasms, both bearing a CVC. Their clinical and microbiological characteristics are shown in Table 1.

Table 1: Clinical and microbiological characteristics of the 2 cases of IE at our institution.

In presence of pathogens known for their ability to colonize intravascular devices such as Candida parapsilosis and other Candida species, S. aureus and Enterococcus spp. It is necessary to proceed with the removal of the catheter as soon as possible, because the permanence of the infectious source significantly reduces the action and effectiveness of the antibiotic therapy, with the risk of serious complications as disseminated infections or endocarditis.

1. Amabile E, Totaro M, Cappelli LV, Minotti C, Micozzi A (2024) A Case of central venous catheter-related Candida parapsilosis fungemia evolved to disseminated infection in a neutropenic patient with blast crisis of chronic myeloid leukemia. Mediterr J Hematol Infect Dis 16:e2024013.

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