What is the treatment for a Candida infection?

Treatment of Candida Infections

The treatment of Candida infections should be based on the specific site of infection, severity of illness, and susceptibility of the isolated organism, with echinocandins (caspofungin, micafungin, anidulafungin) recommended as first-line therapy for invasive candidiasis and candidemia in most adult patients. 1

Candidemia and Invasive Candidiasis

First-line Treatment Options:

• For non-neutropenic adults with candidemia, an echinocandin is the preferred initial therapy (caspofungin: 70-mg loading dose, then 50 mg daily; anidulafungin: 200-mg loading dose and then 100 mg daily; or micafungin: 100 mg daily) 1, 2
• For critically ill patients, initial therapy with an echinocandin is strongly recommended over a triazole due to better efficacy and fungicidal activity 1, 3
• Fluconazole (loading dose of 800 mg [12 mg/kg], then 400 mg [6 mg/kg] daily) is a reasonable alternative for less critically ill patients who have no recent azole exposure 1
• Central venous catheter removal is strongly recommended for non-neutropenic patients with candidemia 1

Duration of Therapy:

• Treatment should continue for 14 days after documented clearance of Candida from the bloodstream and resolution of symptoms attributable to candidemia 1
• Follow-up blood cultures should be performed to document clearance of the infection 1

Special Populations:

• For neutropenic patients, an echinocandin or lipid formulation of amphotericin B (3-5 mg/kg daily) is recommended 1
• For neonates with disseminated candidiasis, amphotericin B deoxycholate (1 mg/kg daily) is recommended 1
• Fluconazole (12 mg/kg daily) is a reasonable alternative in neonates who have not been on fluconazole prophylaxis 1

Candida Infections by Site

Mucosal Candidiasis (Oropharyngeal/Esophageal):

• For mild oropharyngeal candidiasis: clotrimazole troches (10 mg 5 times daily) or miconazole mucoadhesive buccal tablet (50 mg) applied once daily for 7-14 days 1
• For moderate to severe disease: oral fluconazole (100-200 mg daily) for 7-14 days 1
• For fluconazole-refractory disease: itraconazole solution (200 mg daily) or posaconazole suspension (400 mg twice daily for 3 days then 400 mg daily) 1

Vulvovaginal Candidiasis:

• Topical antifungal agents (clotrimazole, miconazole) or oral fluconazole (150 mg single dose) are effective for uncomplicated cases 1, 4
• For recurrent vulvovaginal candidiasis, fluconazole (150 mg weekly for 6 months) or monthly vaginal nystatin suppositories may be used 1, 4

Urinary Tract Candidiasis:

• For fluconazole-susceptible organisms: oral fluconazole (200 mg [3 mg/kg] daily) for 2 weeks 1
• For fluconazole-resistant C. glabrata: amphotericin B deoxycholate (0.3-0.6 mg/kg daily) for 1-7 days or oral flucytosine (25 mg/kg 4 times daily) for 7-10 days 1
• Removal of indwelling bladder catheters is strongly recommended when feasible 1

Intra-abdominal Candidiasis:

• Treatment should include source control with appropriate drainage and/or debridement 1
• Fluconazole is appropriate for treatment if C. albicans is isolated 1
• For fluconazole-resistant Candida species, therapy with an echinocandin is appropriate 1
• For critically ill patients, initial therapy with an echinocandin is recommended 1

Treatment Based on Candida Species

C. albicans:

• Fluconazole (400 mg [6 mg/kg] daily) is effective for most infections 1, 5
• Echinocandins are also highly effective against C. albicans 2, 3

C. glabrata:

• Echinocandins are preferred due to increasing fluconazole resistance 1
• For urinary tract infections: amphotericin B deoxycholate (0.3-0.6 mg/kg daily) with or without flucytosine 1

C. krusei:

• Intrinsically resistant to fluconazole; use echinocandins, amphotericin B, or voriconazole 1

C. parapsilosis:

• More susceptible to fluconazole; may have higher MICs to echinocandins 1, 2

Common Pitfalls and Caveats

• Failure to remove central venous catheters in non-neutropenic patients with candidemia can lead to persistent infection 1
• Inadequate duration of therapy is a common cause of treatment failure; continue treatment for at least 14 days after blood culture clearance 1
• Overlooking ocular involvement; all patients with candidemia should have a dilated retinal examination 1
• Failing to adjust therapy based on species identification and susceptibility testing can lead to treatment failure 1, 6
• Not considering step-down therapy to fluconazole after clinical improvement for susceptible isolates increases costs and potential for drug interactions 3

Emerging Resistance Considerations

• Increasing resistance to azoles, particularly in C. glabrata, necessitates species identification and susceptibility testing 6
• Consider local epidemiology and institutional resistance patterns when selecting empiric therapy 7
• For patients with prior azole exposure, echinocandins are preferred for empiric therapy 1, 3