971

Abstract

Case Reports: Candidemia is the fourth most common cause of nosocomial bloodstream infections in the United States. Guidelines recommend fluconazole or an echinocandin as initial empiric therapy for most non-neutropenic adult patients with candidemia. There is a lack of published data in morbidly obese patients and the optimal dose of fluconazole has not been described. A 28-year-old male with a BMI of 79 kg/m2 (295 kg) was admitted with acute respiratory distress. The patient was intubated on the second day of hospitalization and developed fevers and leukocytosis. The patient was started on empiric antimicrobial therapy. On Day 11 after admission, the urine culture showed Candida albicans. On Day 12, the patient was initiated on empiric fluconazole (800 mg loading dose followed by 400mg daily) therapy due to multiple risk factors for candidemia, worsening clinical status, and a suspected candidemia secondary to the central line. Preliminary laboratory findings indicated yeast in the blood on Day 15. Fluconazole was discontinued and empiric therapy with micafungin was initiated on Day 15 and the PICC line was removed. On Day 18, the blood culture results confirmed Candida albicans and a new PICC line was placed. Micafungin was changed to intravenous fluconazole 1200mg over 6 hours daily and continued for 12 days (total of 17 days of antifungal therapy). The dose of fluconazole used was based on a previously published case report of high dose fluconazole in a morbidly obese patient. The patient was successfully extubated at a tertiary care hospital and transferred back on BiPAP. All follow-up blood cultures (after the original Candida albicans culture on Day 15) were negative for fungal organisms. Clinical improvement was observed and no adverse effects attributable to fluconazole were observed.Data regarding fluconazole dosing in morbidly obese patients is lacking. We describe a case of candidemia in a 28-year-old male (BMI of 79 kg/m2) successfully treated with intravenous fluconazole 1200mg infused over 6 hours daily. Although there exists limited data for high dose fluconazole for other indications, this case report represents the second published report of high dose fluconazole used in a morbidly obese patient successfully and without any adverse effects despite high doses. Given the increasing prevalence of obesity and its recognition by the World Health Organization as a global pandemic, current dosing recommendations may be suboptimal for obese patients. Further studies are needed to evaluate antimicrobial dosing in the obese population.