How do I interpret heavy growth of Candida sp. from sputum of my patient with COPD and pneumonia?

Chances are our patient has been on antibiotics and is being treated with either inhaled and/or systemic corticosteroids which may all contribute to yeast overgrowth in the respiratory and GI tracts.   Fortunately, in the absence of severe immunocompromised state such as neutropenia,  Candida sp. in  respiratory specimens (including those obtained by bronchoscopy) is only rarely associated with pneumonia (1,2).   So no antifungal therapy seems to be indicated in our patient, unless oral candidiasis (e.g. either thrush or the atrophic variety) is also simultaneously present.  Time to examine the mouth!

1. El-Ebiary M, Torres A, Fabregas N, et al. Significance of the isolation of Candida species from respiratory samples in critically ill, non-neutropenic  patients.  Am J Resp Crit Care Med 1997;156:583-590

2. Rello J, Wsandi ME, Diaz E, et al. The role of Candida sp. isolated from bronchoscopic samples in non-neutropenic patients. Chest 1998;114:146-49

How do I interpret heavy growth of Candida sp. from sputum of my patient with COPD and pneumonia?

When should I consider treating my hospitalized patients with asymptomatic bacteruria (ASB)?

The great majority of hospitalized patients with ASB do not need treatment with antibiotics.

In fact, there are only a couple of conditions for which treatment of ASB is indicated:  pregnant women (due to risk of pyelonephritis and low-birth infants/pre-term delivery) and before  GU instrumentation, such as transurethral resection of the prostate or other GU procedures for which mucosal bleeding is anticipated (1).  

So for the great majority of our hospitalized patients, including the elderly, diabetic women, institutionalized residents of long-term facilities, and spinal cord injury patients treatment of ASB is not indicated.  Even in the case of renal transplant patients, supportive evidence for the  use of prophylactic antibiotics in ASB is so far lacking (2).  

The estimated prevalence of ASB varies widely in the population,  with rates of 15-20% among community-dwelling women > 70 yrs of age, and 5-10% for men>65 yrs for community-dwelling men. In long-term care facility residents, 25-50% of women, 15-40% of men, and 100% of those with chronic indwelling catheters have ASB (3).  

So keep these rates in mind before attributing patient’s symptoms to ASB (ie, patient’s presentation may have nothing to do with urine findings).  It’s also worth emphasizing that pyuria accompanying ASB is not an indication for treatment.

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References

1. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-54.  https://academic.oup.com/cid/article/40/5/643/363229

2. Coussement J, Abramowicz D. Should we treat asymptomatic bacteriuria after renal transplantation? Nephrol Dial Transplant 2013;0:1-3. https://academic.oup.com/ndt/article/29/2/260/1913512

3. Nicolle LE. Asymptomatic bacteriuria in older adults. Geriatrics & Aging 2003;6:24-28. https://www.healthplexus.net/files/content/2003/October/0609bacteriuria.pdf

When should I consider treating my hospitalized patients with asymptomatic bacteruria (ASB)?

My 70 year old male patient with recent hip fracture has developed fevers with sterile pyuria. How do I interpret the sterile pyuria in this patient?

Although historically sterile pyuria has been associated with genitourinary (GU) tuberculosis, there are many more common causes to consider in the hospitalized patient. 

Recent antibiotic exposure (within past 2 weeks) in the setting of UTI is one of the most frequent causes.  Prostatitis is also an often overlooked cause.  About 15% of hospitalized patients with systemic infections outside of the GU tract (e.g. pneumonia) may also have sterile pyuria. Non-infectious causes include current or recent catheterization of bladder, urinary stones, stents, GU malignancy, papillary necrosis,  and analgesic nephropathy. 

I would start out with a prostate exam.

Reference:

Wise GJ, Schlegel PN. Sterile pyuria. N Engl J Med 372;11:1048-54.

My 70 year old male patient with recent hip fracture has developed fevers with sterile pyuria. How do I interpret the sterile pyuria in this patient?