Management of Candidiasis

An echinocandin (caspofungin, loading dose 70 mg, then 50 mg daily; micafungin, 100 mg daily; anidulafungin, loading dose 200 mg, then 100 mg daily) is recommended as initial therapy. ( S/H )

Fluconazole intravenous or oral, 800 mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) daily is an acceptable alternative to an echinocandin as initial therapy in selected patients, including those who are not critically ill and who are considered unlikely to have a fluconazole resistant Candida species. ( S/H )

Testing for azole susceptibility is recommended for all bloodstream and other clinically relevant Candida isolates. Testing for echinocandin susceptibility should be considered in patients who have had prior treatment with an echinocandin and among those who have infection with C. glabrata or C. parapsilosis. ( S/L )

Transition from an echinocandin to fluconazole (usually within 5-7 days) is recommended for patients who are clinically stable, have isolates that are susceptible to fluconazole (e.g., C. albicans), and have negative repeat blood cultures following initiation of antifungal therapy. ( S/M )

For infection due to C. glabrata, transition to higher-dose fluconazole 800 mg (12 mg/kg) daily or voriconazole 200-300 mg (3-4 mg/kg) twice daily should be considered only among patients with fluconazole-susceptible or voriconazole-susceptible isolates. ( S/L )

Lipid formulation amphotericin B (AmB) (3-5 mg/kg daily) is a reasonable alternative if there is intolerance, limited availability, or resistance to other antifungal agents. ( S/H )

Transition from AmB to fluconazole is recommended after 5-7 days among patients who have isolates that are susceptible to fluconazole, who are clinically stable, and in whom repeat cultures on antifungal therapy are negative. ( S/H )

Among patients with suspected azole and echinocandin-resistant Candida infections, lipid formulation AmB (3-5 mg/kg/d) is recommended. ( S/L )

All non-neutropenic patients with candidemia should have a dilated ophthalmological examination, preferably performed by an ophthalmologist, within the first week after diagnosis. ( S/L )

Follow-up blood cultures should be performed every day or every other day to establish the time point at which candidemia has been cleared. ( S/L )

Recommended duration of therapy for candidemia without obvious metastatic complications is for 2 weeks after documented clearance of Candida species from the bloodstream and resolution of symptoms attributable to candidemia. ( S/M )