Candida albicans Fungaemia following Traumatic Urethral Catheterisation in a Paraplegic Patient with Diabetes Mellitus and Candiduria Treated by Caspofungin

A 58-year-old paraplegic male, with long-term indwelling urethral catheter, developed catheter block. The catheter was changed, but blood-stained urine was drained intermittently. A long segment of the catheter was seen lying outside his penis, which indicated that the balloon of Foley catheter had been inflated in urethra. The misplaced catheter was removed and a new catheter was inserted correctly. Gentamicin 160？mg was given intravenously; meropenem 1 gram every eight hours was prescribed; antifungals were not given. Twenty hours later, this patient developed distension of abdomen, tachycardia, and hypotension; he was not arousable. Computed tomography of abdomen revealed inflamed uroepithelium of right renal pelvis and ureter, 4？mm lower ureteric calculus with gas in right ureter proximally, and vesical calculus containing gas in its matrix. Urine and blood culture yielded Candida albicans. Identical sensitivity pattern of both isolates suggested that the source of the bloodstream infection was most likely urine. Both isolates formed consistently high levels of biofilm formation in vitro as assessed using a biofilm biomass stain, and high levels of resistance to voriconazole were observed. Both amphotericin B and caspofungin showed good activity against the biofilms. HbA1c was 111？mmol/mol. This patient was prescribed human soluble insulin and caspofungin 70？mg followed by 50？mg daily intravenously. He recovered fully from candidemia. 1. Introduction Candidal colonisation of mucosal sites ordinarily poses no threat to the health of the host. Problems develop when the body’s defenses are abridged as occurs with diabetes mellitus, human immunodeficiency virus infection, neutropenia, and immunosuppression accompanying organ transplantation or when patients undergo certain procedures, such as bladder catheterisation or urologic surgery. Breaches in defense allow increased colonisation of mucosal surfaces and sometimes candidemia, in which case the organism can be carried to the kidneys. These predisposing conditions permit the survival of blood-borne or locally invasive yeast in sufficient numbers to evade the local or systemic immunity [1]. Medical devices such as stents and catheters have been shown to support colonisation and biofilm formation by Candida spp. [2]. The Candida biofilm lifestyle results in antifungal drug resistance and protection of the fungus from host defenses [3]. Candidemia is frequently associated with the biofilm growth of Candida organisms on medical devices such as a venous catheter or urinary catheter. In mice infected with