What is the next step in managing a patient with a suspected Candida infection who is afebrile?

From the Guidelines

For a patient with suspected Candida infection who is afebrile, the next step should be to obtain appropriate cultures before initiating empiric antifungal therapy, and consider starting empiric therapy with an echinocandin such as caspofungin (70 mg loading dose followed by 50 mg daily) or micafungin (100 mg daily) in critically ill patients or those with risk factors for invasive candidiasis, as recommended by the 2016 update by the Infectious Diseases Society of America 1.

When managing a patient with a suspected Candida infection who is afebrile, it is crucial to prioritize the collection of appropriate cultures from suspected sites of infection, including blood, urine, wounds, or catheter tips. This step is essential for guiding targeted antifungal therapy.

• The choice of initial empiric antifungal therapy depends on the severity of the illness and the presence of risk factors for invasive candidiasis.
• For critically ill patients or those with risk factors, an echinocandin such as caspofungin or micafungin is recommended due to its strong safety profile, convenience, and early fungicidal activity 1.
• For less severe cases, fluconazole may be considered, especially if the patient has not had recent azole exposure and is not critically ill 1.
• Removing any potentially infected catheters or devices is also a critical step in managing suspected Candida infections, as these can be a source of infection 1.
• The absence of fever does not exclude the possibility of a Candida infection, particularly in immunocompromised patients who may not mount a typical febrile response.
• Assessing for risk factors such as recent antibiotic use, central venous catheters, total parenteral nutrition, immunosuppression, or recent abdominal surgery is also important in guiding the management of these patients.
• Once culture and susceptibility results are available, antifungal therapy should be tailored accordingly, with treatment duration typically ranging from 14 days after the first negative blood culture for candidemia to several weeks for deep-seated infections 1.

It's also important to note that the management of Candida infections should be based on the most recent and highest-quality evidence available, and guidelines such as those provided by the Infectious Diseases Society of America should be consulted for the most up-to-date recommendations 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Steps in Managing a Patient with Suspected Candida Infection who is Afebrile

• The patient's clinical status, the site of infection, and the pharmacokinetics and pharmacodynamics of the antifungal agent should be considered when deciding on the next step in management 2.
• Removing predisposing factors, such as indwelling catheters and antibiotics, will clear candiduria in almost 50% of asymptomatic patients 3.
• For patients with symptomatic Candida urinary tract infections, fluconazole is the antifungal agent of choice, achieving high urine concentrations with the oral formulation 3, 2.
• If the patient has a ureteral stent, colonization of the stent due to Candida is common and can be responsible for symptomatic infection, and anti-fungal therapy should be introduced before the change of the stent 4.
• The decision to initiate antifungal therapy should be based on the patient's risk factors, such as the use of antimicrobial agents, central intravascular devices, and recurrent gastrointestinal perforations 5.

Considerations for Antifungal Therapy

• Fluconazole is the drug of choice for the treatment of Candida urinary tract infections and for the management of candiduria on ureteral stent 2, 4.
• The duration of antifungal therapy before surgery or removal of the ureteral stent is not well established, but it is recommended to initiate therapy 48 hours to 3 weeks before the procedure 4.
• The choice of antifungal agent and the duration of therapy should be individualized based on the severity of the infection, comorbid conditions, and the Candida species causing the infection 6.