SUN-169 A Case of Candidemia in a Patient with Diabetes on Canagliflozin Following Urologic Procedure

Background: SGLT-2 inhibitors increase the incidence of urogenital infections however, its association with candidemia following urologic procedure is rare. We report a case of candidemia in a patient with diabetes, treated with canagliflozin following ureteric stent placement. Clinical Case: A 38-year-old female with type II diabetes mellitus on canagliflozin presented to the ED for high-grade fever (103(o)F) and left lower quadrant pain for 3 days. She was febrile and had left flank tenderness. Urinalysis showed pyuria, bacteriuria, and nitrites. HbA1C was 7.5. A CT abdomen and pelvis without contrast showed an obstructive 5 mm left distal ureteral stone with mild hydroureteronephrosis. She was empirically treated with IV ceftriaxone 1 gram and a ureteral stent was placed for obstructing nephrolithiasis. She was discharged on cefdinir and was continued on canagliflozin for her diabetes. Ten days later, she again presented for intermittent fever and left flank pain and was found to be hypotensive (96/58 mmHg), tachycardic (104 bpm) & febrile (102.8(o)F). Laboratory studies showed worsening leukocytosis, pyuria, bacteriuria, positive urine nitrites, and small leukocyte esterase. Repeat CT scan showed stable position of the ureteral stent without hydroureteronephrosis. She was diagnosed with acute complicated pyelonephritis and was started on broad-spectrum antibiotics and aggressive hydration. Her canagliflozin was discontinued and she was started on basal-bolus insulin regimen for blood glucose control. Urine cultures from presentation grew Klebsiella pneumonia however blood cultures remained negative. 48 hours later, her blood cultures became positive for Candida glabrata and she was started on IV micafungin with gradual defervescence. Repeat cystoureteroscopy showed the presence of fungal elements in the left kidney. Urine culture from left renal pelvis also grew C. glabrata sensitive to fluconazole. Dilated fundus examination and transthoracic echocardiogram were unremarkable. The patient was eventually discharged on oral fluconazole for 2 weeks and cefazolin for 1 week and was recommended to avoid SGLT-2 inhibitors in future due to the risk of candidemia. Conclusion: SGLT-2 inhibitors lead to colonization of urine with candida and therefore patient undergoing urologic procedures are at higher risk of developing candidemia. This is the first case demonstrating the possible role of SGLT-2 inhibitors leading to candidemia following urologic procedures. Reference: 1. Kauffman CA. Diagnosis and management of fungal urinary tract infection. Infectious disease clinics of North America. 2014;28(1):61-74.2. Dariane C, Cornu JN, Esteve E, Cordel H, Egrot C, Traxer O, et al. [Fungal infections and ureteral material: How to manage? 2015;25(6):306-11.