Background: Fungemia due to Candida auris is a highly consequential infection in the setting of left ventricular assist devices (LVADs). Fosfmanogepix is a promising antifungal agent for invasive candidiasis. This case aims to report the first use of fosfmanogepix as part of a treatment regimen for an LVAD-associated C. auris infection.
Methods: The patient is a 46-year-old male with nonischemic cardiomyopathy resulting in HFrEF, requiring a HeartMate III implantation 6 years prior. Following LVAD placement, his clinical course is notable for chronic LVAD driveline infections with multiple pathogens, including MSSA, Pseudomonas, and Candida auris. The patient required multiple I&D procedures and was on chronic antimicrobial suppression therapy prior to acute admission. His non-infectious history is also remarkable for intracranial hemorrhage, RV dysfunction, heparin-induced thrombocytopenia, and ESRD requiring hemodialysis.
Outcome: The patient presented for concern of increased purulent discharge from the LVAD driveline and requiring admission for sepsis secondary to C. auris fungemia, which persisted for a period of 2 months, finally clearing with LVAD extraction and the addition of fosmanogepix, an investigational antifungal agent with excellent in vitro activity against. C. auris. PET CT demonstrated FDG uptake along the the LVAD outflow tract, surrounding the LVAD pump, and the driveline, consistent with infection. IV amphotericin B, IV micafungin, and PO flucytosine were begun for treatment of fungemia. Additionally, a new right atrial vegetation was noted on the ICD lead, requiring ICD lead extraction.
Following multidisciplinary discussions, he was approved for LVAD extraction with plan for replacement once fungemia was cleared. He underwent LVAD explant with placement of ProTec Duo temp VAD. Once source control was achieved by extraction of the infected LVAD, approval was able to be obtained for IV fosfmanogepix (via investigational protocol). Repeat cultures following the start of fosfmanogepix demonstrated resolution of fungemia. One month following, he underwent implantation of new HeartMate III LVAD and RVAD CentriMag cannulation. The RVAD was successfully decannulated 6 weeks later with continued clearance of C. auris fungemia.
Conclusion: This case demonstrated successful clearance of LVAD-associated C. auris fungemia, which allowed for the patient to undergo successful surgical exchange of HeartMate III device. This case also highlights the multidisciplinary surgical approach for explantation and recannulation of mechanical circulatory support devices complicated by this infection.
