Case Report

A 20-year-old female with T-cell ALL was admitted with febrile neutropenia and Rothia mucilaginosa bacteremia. Initial treatment with piperacillin-tazobactam changed to cefepime; cefepime continued for 58 days, until count recovery. Her stay was complicated by doxorubicin induced heart failure which led to pediatric intensive care unit (PICU) admission. In the PICU a Foley catheter was placed to initiate continuous renal replacement. Micafungin prophylaxis was started, however sixteen days later she developed fever (38^oC). Cultures were obtained, micafungin was discontinued and liposomal amphotericin was initiated. Subsequently, IV fluconazole was added when urine and blood cultures grew Candida kefyr. Therapy initially cleared her candidemia however candiduria persisted. Fluconazole was discontinued and caspofungin was initiated. Additionally, conventional amphotericin bladder irrigations were started. Two days later blood and urine cultures were sterile, antifungals continued, but Candida kefyr candiduria recurred. After six days, amphotericin bladder irrigation was discontinued and an innovative treatment with fluconazole bladder irrigations was started. One-hundred mg of fluconazole was added to 250 mLs of sterile water for irrigation. This was instilled in the bladder to dwell for two hours, four times daily. Resolution of candiduria was seen within 24 hours of the first irrigation. Fluconazole bladder irrigation continued for five days and caspofungin continued for 25 days. The Candida kefyr did not recur.

Fluconazole bladder irrigation in a patient with Candida kefyr candiduria

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