Successful Eradication of Candida Central Venous Catheter Infection With Ambisome Line Lock in Factitious Illness

Abstract

T o the Editor: Central venous catheter (CVC) removal is recommended in fungal infection (1); however, 4 cases of eradication have been described using liposomal Amphotericin-B (Ambisome) (2). We report eradication of CVC/systemic Candida infection in a parenteral nutrition-dependent child to support these data. Seven episodes of sepsis, 9 CVC replacements, and widespread venous thrombosis occurred during >7 months. During an acute febrile illness, urine and through-CVC blood grew Candida albicans; there was no evidence of endocarditis or ophthalmitis, but renal ultrasound showed bilateral fungal masses. Empirical antimicrobials were given including caspofungin 50 mg/m 2 once daily, and taurolidine as CVC ''lock'' for 6 h/day. Sensitivity data lead to substitution with fluconazole, but after 5 days without clinical response Candida was again isolated. Treatment was changed to 3 mg/kg daily Ambisome; fever continued and 11 days later Ambisome solution 4 mg/mL was substituted for taurolidine. For >14 days, pyrexia resolved and C-reactive protein normalised; 4 weeks after the last positive isolate, urine and through-CVC blood culture were negative and renal ultrasound appeared normal. Three weeks after stopping Ambisome the CVC was removed for Gram-negative sepsis; blood and catheter cultures were negative for Candida indicating complete resolution of the previous infection. Suspicion of factitious illness lead to prohibition of unsupervised visiting, with resolution of diarrhoea and return to full-enteral feeding. Our case strengthens the observation that Ambisome can completely eradicate CVC Candida infection (2) and may be considered in parenteral nutrition-dependent patients with difficult venous access. Unusually frequent CVC infections must always raise concerns regarding factitious illness (3).