Invasive candidiasis / Candidemia - see also Candida endocarditis
[Clin Infect Dis 2016;62:e1-50.]
General Management
- Removal of central venous catheter (CVC) and/or peritoneal dialysis catheter generally recommended in non-neutropenic patients when the source is presumed to be the CVC, but controversial for neutropenic patients as source is often the GI tract.
- Discontinue broad spectrum antibiotics if possible.
- Repeat blood cultures (daily or every two days) to ensure sterilization.
- Fundoscopic examination should be considered. For neutropenic patients, wait until after recovery from neutropenia.
- For positive Candida spp cultures:
C. glabrata – some resistance with low dose fluconazole; may be overcome with high dose therapy.
C. krusei - resistant to fluconazole; can use voriconazole.
C. lusitaniae - usually resistant to amphotericin B.
Candida albicans
Candida tropicalis
Candida parapsilosis
Candida glabrata
Candida krusei
| Empiric Therapy | Dose | Duration |
|---|---|---|
| Anidulafungin | 200mg IV once then 100mg IV daily |
Minimum 14 days after first negative blood culture, no metastatic complications, and resolution of neutropenia (if present), and signs & symptoms attributable to candidemia. Can switch to fluconazole if patient clinically stable, isolate susceptible and negative repeat blood cultures. |
| or | ||
| Caspofungin | 70mg IV once then 50mg IV daily |
Minimum 14 days after first negative blood culture, no metastatic complications, and resolution of neutropenia (if present), and signs & symptoms attributable to candidemia. Can switch to fluconazole if patient clinically stable, isolate susceptible and negative repeat blood cultures. |
| or | ||
| Micafungin | 100mg IV daily |
Minimum 14 days after first negative blood culture, no metastatic complications, and resolution of neutropenia (if present), and signs & symptoms attributable to candidemia. Can switch to fluconazole if patient clinically stable, isolate susceptible and negative repeat blood cultures. |
Alternative only if not critically ill and no azole exposure in past 3 months
| Empiric Therapy | Dose | Duration |
|---|---|---|
| Fluconazole |
800mg (12mg/kg) IV loading dose then 400mg (6mg/kg) IV/PO daily |
Minimum 14 days after first negative blood culture, no metastatic complications, and resolution of neutropenia (if present), and signs & symptoms attributable to candidemia. |
Intolerance or resistance to above antifungal agents
| Empiric Therapy | Dose | Duration |
|---|---|---|
| Amphotericin B | 0.7mg/kg IV daily | Minimum 14 days after first negative blood culture, no metastatic complications, and resolution of neutropenia (if present), and signs & symptoms attributable to candidemia. |