Skip to main content

Candida bloodstream infection under veno-arterial ECMO therapy

Cavayas et al. recently described invasive fungal infections in patients under extra-corporeal membrane oxygenation (ECMO) of the Extracorporeal Life Support Organization registry [1]. They found a 1.2% prevalence of Candida bloodstream infections (BSI). However, we highlighted the heterogeneity of this mixed population treated with veno-venous (VV) and veno-arterial (VA) ECMO and the scarce available data, in particular the delay from ECMO to infection [2].

As no specific report is available on Candida BSI under VA-ECMO, we investigated the incidence and timing of this complication in our large database of 150 VA-ECMO (January 2013 to January 2017) who survived more than 24 h (Table 1). Our surveillance protocol includes systematic blood culture (BC) once daily, since ECMO implantation up to 5 days after support withdrawal. Of the 2163 BC samples collected, either as routine or “on-demand” by the attending physician, 192 were positive; after exclusion of contaminants, 117 BC (61%) were related to bacterial infection in 46 patients. Only 7 (0.04%) were positive for yeasts, for a total of 5 BSI episodes in 4 patients. BSI rate was 43 cases/1.000 days of ECMO support. All yeast BSI were positive for Candida spp. In all cases, candidemia occurred in the third week after VA-ECMO implantation: delay between ECMO implantation and first positive BC was 17 [16–19] days. In one patient, candidemia occurred 4 days after ECMO withdrawal. Weaning from ECMO occurred in all 4 patients after 20 [17–21] days; moreover, only the patient with candidemia after ECMO withdrawal survived. Among the 46 patients with bacterial BSI, 27 died.

Table 1 Patients characteristics

Prevalence of invasive Candida disease ranges from 0 to a third of patients under ECMO [3, 4]. However, studies included both VV and VA-ECMO, without clear distinction between Candida BSI and other forms of Candida infections and without data on the timing of BSI occurrence. Moreover, whether BC were performed systematically or on-demand remains unknown. While it was difficult to draw conclusions with these heterogeneous populations, our results highlight that Candida BSI is rare and occurs late during the ECMO course. On the opposite, early septic shock under VA-ECMO is frequent and largely due to bacteria [5]. Consequently, antifungal therapy should not be part of the first-line empiric antimicrobial therapy in case of septic shock occurring within the first 2 weeks of ECMO support, unless indicated for other conditions (i.e., prolonged febrile neutropenia or tertiary peritonitis). Sepsis under prolonged mechanical support should raise the possibility of invasive Candida infection.

Availability of data and materials

Available on request at


  1. 1.

    Cavayas YA, Yusuff H, Porter R. Fungal infections in adult patients on extracorporeal life support. Crit Care. 2018;22:98.

    Article  Google Scholar 

  2. 2.

    Mongardon N, Constant O, Taccone FS, et al. Appraisal of fungal infections during ECMO therapy. Crit Care. 2018;22:145.

    Article  Google Scholar 

  3. 3.

    Kim GS, Lee KS, Park CK, et al. Nosocomial infection in adult patients undergoing veno-arterial extracorporeal membrane oxygenation. J Korean Med Sci. 2017;32:593–8.

    CAS  Article  Google Scholar 

  4. 4.

    Aubron C, Cheng AC, Pilcher D, et al. Infections acquired by adults who receive extracorporeal membrane oxygenation risk factors and outcome. Infect Control Hosp Epidemiol. 2013;34:24–30.

    Article  Google Scholar 

  5. 5.

    Schmidt M, Bréchot N, Hariri S, et al. Nosocomial infections in adult cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation. Clin Infect Dis. 2012;55:1633–41.

    CAS  Article  Google Scholar 

Download references


Not applicable.

Letter to the editor

Letter to the editor on (1) the study by Cavayas et al., 2018, “Fungal infection in adult patients on extracorporeal life support” (Critical Care 2018, 22:98) and (2) the letter by Mongardon et al., 2018, “Appraisal of fungal infections during ECMO therapy” (Critical Care 2018, 22:145).


No funding was required.

Author information




QDR and NM wrote the manuscript; FB, RL, FST, and OL helped to draft the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Nicolas Mongardon.

Ethics declarations

Ethics approval and consent to participate

IRB approval of the “Comité d’Éthique de la Recherche en Anesthésie-Réanimation” (CERAR), IRB 00010254-2019-031.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This comment refers to the article available at

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

de Roux, Q., Botterel, F., Lepeule, R. et al. Candida bloodstream infection under veno-arterial ECMO therapy. Crit Care 23, 314 (2019).

Download citation