From the Guidelines
The treatment approach for Candida infections should prioritize the use of echinocandins, such as caspofungin, as initial therapy for invasive candidiasis, with fluconazole as step-down therapy for susceptible isolates 1.
Treatment Approach
The treatment of Candida infections depends on the site and severity of the infection.
- For uncomplicated vulvovaginal candidiasis, a single 150mg dose of oral fluconazole or topical azoles like clotrimazole 1% cream applied for 7-14 days are effective first-line treatments.
- Oropharyngeal candidiasis typically responds to clotrimazole troches (10mg) five times daily or nystatin suspension (100,000 units/mL) 4-6mL four times daily for 7-14 days.
Invasive Candidiasis
For invasive candidiasis, echinocandins such as caspofungin (70mg loading dose, then 50mg daily) are preferred initial therapy, with fluconazole (800mg loading dose, then 400mg daily) as step-down therapy for susceptible isolates 1.
- Treatment duration for invasive infections typically continues for 14 days after blood cultures become negative.
Candida Esophagitis
For Candida esophagitis, oral fluconazole 200-400mg daily for 14-21 days is recommended 1.
Antifungal Susceptibility Testing
Antifungal susceptibility testing may guide therapy for resistant strains.
Underlying Risk Factors
Addressing underlying risk factors like immunosuppression, broad-spectrum antibiotic use, or uncontrolled diabetes is crucial for preventing recurrence.
Severe or Persistent Infections
Severe or persistent infections may require longer treatment courses or combination therapy. Note that amphotericin B deoxycholate (AmB-d) administered at a dosage of 0.5–1.0 mg/kg daily or a lipid formulation of AmB (LFAmB) administered at a dosage of 3–5 mg/kg daily are alternatives if there is intolerance to or limited availability of other antifungals 1.
From the FDA Drug Label
Candidemia in non-neutropenic patients and other deep tissue Candida infections See Table 1. Patients should be treated for at least 14 days following resolution of symptoms or following last positive culture, whichever is longer.
The treatment approach for Candida infections includes:
- Candidemia in non-neutropenic patients and other deep tissue Candida infections: treatment for at least 14 days following resolution of symptoms or last positive culture.
- Esophageal Candidiasis: treatment for a minimum of 14 days and for at least 7 days following resolution of symptoms. The recommended dosing regimen is outlined in Table 1 2. Key points:
- The dose may be adjusted based on the severity and nature of the infection.
- Patients should be treated with an intravenous infusion regimen initially, and an oral regimen may be considered after significant clinical improvement.
From the Research
Treatment Approach for Candida Infections
The treatment approach for Candida infections varies depending on the severity and location of the infection.
- For symptomatic Candida urinary tract infections, fluconazole is the treatment of choice, as it achieves high urinary levels 3, 4.
- Amphotericin B deoxycholate is an alternative antifungal agent if fluconazole cannot be used due to resistance, allergy, or failure 3.
- Other azole antifungals and echinocandins are not recommended for the treatment of urinary tract infections, as they do not reach sufficient urine levels 3, 4.
- For invasive candidiasis, caspofungin and voriconazole are two new antifungals that can be used 5.
- In the intensive care unit setting, early recognition and appropriate management of invasive candidiasis are crucial, and the use of prophylaxis and antifungal agents such as fluconazole and amphotericin B may be necessary 6, 7.
- Removing predisposing factors, such as indwelling catheters and antibiotics, can clear candiduria in almost 50% of asymptomatic patients 4.
- Surgical perspective on invasive Candida infections suggests that prophylaxis or early treatment in high-risk patients is warranted, particularly before invasive/disseminated disease becomes life-threatening 7.