Candida Empyema Thoracis at Two Academic Medical Centers: New Insights Into Treatment and Outcomes

Abstract

Background: Candida empyema thoracis (pleural empyema) is an uncommon manifestation of invasive candidiasis, for which optimal treatment is unknown.

Methods: This is a retrospective study of patients with Candida empyema at 2 academic medical centers from September 2006 through December 2015.

Results: We identified 81 patients with Candida empyema (median age, 62 years; 68% men). Sixty-five percent of patients underwent surgery or an invasive intervention of the thorax or abdomen within the preceding 90 days. Candida empyema originated from intrathoracic (51%) or intra-abdominal sources (20%), spontaneous esophageal rupture (12%), pleural space manipulation (9%), and pneumonia (6%). Eighty-four percent and 41% of patients were intensive care unit residents and in septic shock, respectively, within 3 days of diagnosis. Causative species were Candida albicans (65%), Candida glabrata (26%), Candida parapsilosis (11%), Candida tropicalis (4%), Candida krusei (2%), and Candida dubliniensis (1%). Bacteria were recovered from empyemas in 51% of patients. Concurrent candidemia was diagnosed in only 2% of patients. Management included pleural drainage and antifungal treatment in 98% and 85% of patients, respectively. Mortality at 100 days was 27%, and it was highest for cases stemming from esophageal rupture (67%). Spontaneous esophageal rupture and echinocandin rather than fluconazole treatment were independent risk factors for death at 100 days (P = .003 and .04, respectively); receipt of antifungal therapy was an independent predictor of survival (P = .046).

Conclusions: Candida empyema mortality rates were lower than reported previously. Optimal management included pleural drainage and fluconazole treatment. Superiority of fluconazole over echinocandins against Candida empyema needs to be confirmed in future studies.

Keywords: Candida; azole antifungal; candidiasis; echinocandin; empyema.

Figure 1.

Sources of Candida empyema. Most cases of Candida empyema stemmed from an intrathoracic source or diaphragmatic translocation from an intra-abdominal source. Details of intrathoracic and abdominal sources are summarized in the Table 3 below.

Figure 2.

Mortality of Candida empyema stratified by source of infection. GI, gastrointestinal.