Recurrent Candidemia Due to Extracorporeal Membrane Oxygenation Circuit Seeding in Acute Respiratory Distress Syndrome From COVID-19

Nosocomial infections are a leading complication of prolonged extracorporeal membrane oxygenation (ECMO) therapy, and invasive fungal infections are of particular concern.1 Candida bloodstream infection specifically is associated with poor outcomes in acute respiratory distress syndrome (ARDS) patients on venovenous extracorporeal membrane oxygenation (VV-ECMO) and in lung-transplant recipients.2,3 Here, we present a case of a 27-year-old man who transferred to be evaluated for lung transplantation in November 2021 and developed recurrent candidemia. He initially presented to an outside hospital with COVID-19 that September, developed ARDS, and was placed on VV-ECMO 5 days after intubation. Three weeks following transfer, he developed increasing leukocytosis (white blood cell count [WBC] 24,000/µL). Blood cultures grew Candida albicans. He was started on micafungin at an increased dose of 200 mg daily due to extraction of micafungin by the ECMO circuit,4 but daily blood cultures remained positive. All central lines were removed except for his right internal jugular vein 29 French ProtekDuo (LivaNova, London, United Kingdom) ECMO cannula. Cultures initially cleared, but his leukocytosis worsened, peaking with WBC 33,000/µL. Subsequently, his oxygenator, with fibers comprised of polymethylpentene (Maquet Quadrox oxygenator, Getinge, Sweden) was noted to have visual signs of fungal growth (Figure 1). Consequently, the ECMO oxygenator and tubing were exchanged, but the ECMO cannula was left in place.Figure 1.: Fungal growth is visible on this Maquet Quadrox oxygenator (Getinge, Sweden), shown from two perspectives prior to its exchange.Cultures again grew Candida albicans 1 week later, and he developed a Roth spot in his left eye. A transesophageal echocardiogram (TEE) was negative for vegetations. Persistent seeding of the ECMO cannula was suspected, despite high-dose micafungin therapy. Fluconazole 400 mg daily was administered for 1 month to address this. Micafungin was also continued due to its ability to penetrate biofilms.5 His leukocytosis then resolved, and repeat blood cultures remained negative. The patient underwent successful bilateral lung transplantation and ECMO decannulation in March 2022, and standard-dose micafungin was continued until discharge. He discharged home 4 weeks later, after tracheostomy decannulation and without supplemental oxygen.