From the Guidelines
For an ICU patient with positive blood cultures for Candida, the first-line antimicrobial treatment is an echinocandin such as caspofungin (70 mg loading dose followed by 50 mg daily), micafungin (100 mg daily), or anidulafungin (200 mg loading dose followed by 100 mg daily). These medications should be administered intravenously. The choice of echinocandin is based on their excellent fungicidal activity against most Candida species, favorable safety profiles, and low resistance rates, as recommended by the Infectious Diseases Society of America 1.
Key Considerations
- Echinocandins work by inhibiting the synthesis of β-(1,3)-D-glucan, an essential component of the fungal cell wall.
- Treatment should continue for at least 14 days after the first negative blood culture and resolution of clinical signs of infection.
- After the patient has stabilized and the Candida species has been identified with susceptibility testing, therapy may be de-escalated to fluconazole (800 mg loading dose followed by 400 mg daily) if the isolate is susceptible, as suggested by 1 and 1.
- Removal of any intravascular catheters is also strongly recommended when feasible, as these can serve as a nidus for persistent infection, as noted in 1 and 1.
- Regular blood cultures should be obtained to monitor treatment response until clearance of candidemia is documented, with the goal of minimizing morbidity, mortality, and improving quality of life.
Additional Recommendations
- A dilated funduscopic examination should be performed within the first week after initiation of specific antifungal therapy to check for ocular involvement, as recommended by 1.
- Follow-up blood cultures every day or every other day until demonstration of clearance of Candida from the bloodstream are helpful to establish the appropriate duration of antifungal therapy, as suggested by 1.
From the Research
Antimicrobial Treatment for Candida in ICU Patients
- The first-line antimicrobial treatment for ICU patients with positive blood cultures for Candida is echinocandins 2, 3.
- Echinocandins are the recommended antifungal drug class for the treatment of ICU candidemia 3.
- In case of Candida parapsilosis, antifungal therapy should be switched to intravenous fluconazole 2.
- Indwelling catheters should be removed if feasible 2.
- Daily blood cultures should be taken until persistently negative to exclude ongoing fungaemia 2.
- Antifungal treatment should be continued for at least 14 days after the last positive blood culture, depending on organ involvement and clinical presentation of the patient 2.