What is the treatment for candidemia (yeast in the blood)?

Treatment of Candidemia (Yeast in the Blood)

For candidemia, an echinocandin (caspofungin, micafungin, or anidulafungin) is strongly recommended as first-line therapy for most patients due to superior efficacy and safety profile. 1

Initial Treatment Selection

For Non-neutropenic Patients:

1. First-line therapy:

   • Echinocandin:
     • Caspofungin: 70 mg loading dose, then 50 mg daily
     • Micafungin: 100 mg daily
     • Anidulafungin: 200 mg loading dose, then 100 mg daily 1

2. Alternative therapy (for less critically ill patients without recent azole exposure):

   • Fluconazole: 800 mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) daily 1

3. For suspected azole and echinocandin-resistant Candida:

   • Lipid formulation Amphotericin B: 3-5 mg/kg daily 1

For Neutropenic Patients:

1. First-line therapy:

   • Echinocandin (same dosing as above) 1

2. Alternative therapy:

   • Lipid formulation Amphotericin B: 3-5 mg/kg daily 1
   • Fluconazole: 800 mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) daily (only for non-critically ill patients with no prior azole exposure) 1

Species-Specific Considerations

1. C. albicans:

   • Can step down to fluconazole if susceptible and patient is clinically stable 1

2. C. glabrata:

   • Echinocandin preferred 1
   • Only consider step-down to high-dose fluconazole (800 mg daily) or voriconazole (200-300 mg twice daily) if isolate is proven susceptible 1

3. C. krusei:

   • Echinocandin, lipid formulation Amphotericin B, or voriconazole 1
   • Voriconazole: 400 mg (6 mg/kg) twice daily for 2 doses, then 200 mg (3 mg/kg) twice daily 1, 2

4. C. parapsilosis:

   • Fluconazole preferred due to potentially higher MICs with echinocandins 1

Step-down Therapy

• Transition from echinocandin to fluconazole is recommended after 5-7 days for patients who:

  • Have isolates susceptible to fluconazole (especially C. albicans)
  • Are clinically stable
  • Have negative repeat blood cultures 1

• Transition from Amphotericin B to fluconazole follows the same principles 1

Duration of Therapy

• Treat for 14 days (2 weeks) after:
  • Documented clearance of Candida from bloodstream
  • Resolution of symptoms attributable to candidemia 1

Additional Critical Management Steps

1. Central venous catheter management:

   • Remove central venous catheters as early as possible, especially when the catheter is the presumed source 1

2. Diagnostic follow-up:

   • Perform dilated ophthalmological examination within the first week after diagnosis to rule out endophthalmitis 1
   • Obtain follow-up blood cultures every day or every other day until candidemia has cleared 1

3. For persistent candidemia:

   • Consider imaging of the genitourinary tract, liver, and spleen to rule out metastatic foci of infection 1

Common Pitfalls to Avoid

• Delayed treatment initiation: Early therapy is associated with better outcomes; start antifungal therapy within 24 hours of a positive blood culture 1

• Inadequate source control: Failure to remove infected catheters significantly reduces treatment success 1, 3

• Inappropriate antifungal selection: Using fluconazole for suspected C. glabrata infections should be avoided unless susceptibility is confirmed 1, 3

• Insufficient follow-up: Failing to perform ophthalmological examination or follow-up blood cultures may miss complications requiring extended therapy 1

• Premature discontinuation: Stopping therapy before documented clearance of candidemia and symptom resolution increases risk of relapse 1