Candidiasis

Summary (2016 IDSA Guidelines)

Candidemia in Non-Neutropenic Patients

1. Initial Therapy
   1. Echinocandin is recommended as initial therapy (caspofungin 70 mg loading then 50 mg daily; micafungin 100 mg daily; anidulafungin 200 mg then 100 mg daily).
      1. 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
   2. Fluconazole is acceptable alternative (800 mg loading dose or 12 mg/kg, then 400 mg or 6 mg/kg) daily. For selected patients (not critically ill, low risk of fluconazole resistant Candida)
      1. Testing for azole susceptibility is recommended for all bloodstream and other clinically relevant Candida isolates.
      2. Voriconazole 400 mg (6 mg/kg) twice daily for 2 doses, then 200 mg (3 mg/kg) twice daily is effective for candidemia, but offers little advantage over fluconazole as initial therapy
   3. 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
2. Transitioning
   1. Transition from echinocandin to fluconazole is recommended for patients who are clinically stable, have susceptible isolates (e.g. albicans, and repeat negative blood cultures after starting antifungal therapy, within 5-7 days usually.
   2. 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
   3. For infection due to C. glabrata, transition to higher-dose fluconazole 800 mg (12 mg/kg) daily or voriconazole 200–300 (3–4 mg/kg) twice daily should only be considered among patients with fluconazole-susceptible or voriconazole-susceptible isolate
   4. Voriconazole is recommended as step-down oral therapy for selected cases of candidemia due to C. krusei
3. Duration
   1. Follow-up blood cultures should be performed every day or every other day to establish the time point at which candidemia has been cleared
   2. 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.
4. Other
   1. All nonneutropenic patients with candidemia should have a dilated ophthalmological examination, preferably performed by an ophthalmologist, within the first week after diagnosis

Candidemia in Neutropenic Patients (Differences only)

1. Fluconazole, 400 mg (6 mg/kg) daily, can be used for step-down therapy during persistent neutropenia in clinically stable patients who have susceptible isolates and documented bloodstream clearanc.
2. Voriconazole, 400 mg (6 mg/kg) twice daily for 2 doses, then 200–300 mg (3–4 mg/kg) twice daily, can be used in situations in which additional mold coverage is desired.
3. For infections due to C. krusei, an echinocandin, lipid formulation AmB, or voriconazole is recommended
4. Recommended minimum duration of therapy for candidemia without metastatic complications is 2 weeks after documented clearance of Candida from the bloodstream, provided neutropenia and symptoms attributable to candidemia have resolve.
5. Ophthalmological findings of choroidal and vitreal infection are minimal until recovery from neutropenia; therefore, dilated fundoscopic examinations should be performed within the first week after recovery from neutropenia
6. In the neutropenic patient, sources of candidiasis other than a CVC (eg, gastrointestinal tract) predominate
7. Granulocyte colony-stimulating factor (G-CSF)–mobilized granulocyte transfusions can be considered in cases of persistent candidemia with anticipated protracted neutropenia

Chronic Disseminated (Hepatosplenic) Candidiasis

Invasive Candidiasis in the ICU

Empiric Treatment

Prophylaxis

Intraabdominal Candidiasis

1. The choice of antifungal therapy is the same as for the treatment of candidemia or empiric therapy for nonneutropenic patients in the ICU
2. Treatment of intra-abdominal candidiasis should include source control, with appropriate drainage and/or debridement

Candidal Intravascular Infections

Osteoarticular Infections

CNS Candidiasis

Urinary Tract Infections

Vulvovaginal Candidiasis

Oropharyngeal Candidiasis

• mild disease
  • clotrimazole troches, 10 mg 5 times daily or miconazole mucoadhesive buccal 50-mg tablet applied to the mucosal surface over the canine fossa once daily for 7–14 days are recommended
  • nystatin suspension (100 000 U/mL) 4–6 mL 4 times daily, OR 1–2 nystatin pastilles (200 000 U each) 4 times daily, for 7–14 days
• moderate to severe disease
  • oral fluconazole, 100–200 mg daily, for 7–14 days
• fluconazole refractory disease
  • itraconazole solution, 200 mg once daily OR posaconazole suspension, 400 mg twice daily for 3 days then 400 mg daily, for up to 28 day
  • voriconazole, 200 mg twice daily, OR AmB deoxycholate oral suspension, 100 mg/mL 4 times daily
  • IV echinocandin or IV AmB
• Chronic suppressive therapy is usually unnecessary. If required for patients who have recurrent infection, fluconazole, 100 mg 3 times weekly, is recommended.
• For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections
• For denture-related candidiasis, disinfection of the denture, in addition to antifungal therapy is recommended

Esophageal Candidiasis

• Systemic antifungal therapy is always required. A diagnostic trial of antifungal therapy is appropriate before performing an endoscopic examination
  • Oral fluconazole, 200–400 mg (3–6 mg/kg) daily, for 14–21 days is recommended
  • For patients who cannot tolerate oral therapy, intravenous fluconazole, 400 mg (6 mg/kg) daily, OR an echinocandin (micafungin, 150 mg daily, caspofungin, 70-mg loading dose, then 50 mg daily, or anidulafungin, 200 mg daily) is recommended
  • Consider de-escalating to oral therapy with fluconazole 200–400 mg (3–6 mg/kg) daily once the patient is able to tolerate oral intake
• For patients who have recurrent esophagitis, chronic suppressive therapy with fluconazole, 100–200 mg 3 times weekly, is recommended
• For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections

Reference

1. Pappas, Peter G., Carol A. Kauffman, David R. Andes, Cornelius J. Clancy, Kieren A. Marr, Luis Ostrosky-Zeichner, Annette C. Reboli, et al. “Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America.” Clinical Infectious Diseases 62, no. 4 (February 15, 2016): e1–50. https://doi.org/10.1093/cid/civ933.

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Revision #1
Created Tue, Apr 12, 2022 3:07 AM by Jasper Ho
Updated Tue, Apr 12, 2022 3:40 AM by Jasper Ho