Fluconazole Dosing for Disseminated Candidiasis in Transplant Patients
For disseminated candidiasis in transplant patients, fluconazole should be administered at a loading dose of 800 mg (12 mg/kg) on day 1, followed by 400 mg (6 mg/kg) daily. 1, 2
Initial Treatment Considerations
- For most transplant patients with disseminated candidiasis, fluconazole 400 mg (6 mg/kg) daily following a loading dose is recommended as maintenance therapy 1
- Treatment should continue until all signs, symptoms, and radiological abnormalities have resolved, which typically requires several weeks to months of therapy 1
- Fluconazole is particularly appropriate for patients who are clinically stable and have normal renal function 1
Alternative Initial Therapy Options
For severely ill transplant patients or those with rapidly progressing disseminated candidiasis, consider:
- Lipid formulation of amphotericin B (3-5 mg/kg daily) as initial therapy, followed by step-down to fluconazole after clinical stabilization 1
- An echinocandin (caspofungin: 70-mg loading dose, then 50 mg daily; anidulafungin: 200-mg loading dose, then 100 mg daily; or micafungin: 100 mg daily) may be used as initial therapy in unstable patients 1
Species-Specific Considerations
- For Candida glabrata infections, higher doses of fluconazole may be required, or alternative agents should be considered due to reduced susceptibility 3
- For Candida krusei infections, fluconazole should not be used due to intrinsic resistance; use an echinocandin, lipid formulation of amphotericin B, or voriconazole instead 1, 3
Duration of Therapy
- Treatment should continue for at least 2 weeks after documented clearance of Candida from the bloodstream 1
- For disseminated disease with organ involvement, longer therapy is required until resolution of all lesions on imaging studies 1
- Premature discontinuation of antifungal therapy can lead to relapse 1
Monitoring During Treatment
- Regular blood cultures should be performed to document clearance of candidemia 1
- Ophthalmological examination should be performed to rule out endophthalmitis 1
- Transplant patients should have immunosuppression reduced when possible (without risking graft rejection) until the infection has begun to improve 1
Special Considerations for Transplant Recipients
- Solid organ transplant recipients at high risk of candidiasis may benefit from prophylactic fluconazole (200–400 mg [3–6 mg/kg] daily) 1
- For hematopoietic stem cell transplant recipients, fluconazole 400 mg daily is recommended during the period of neutropenia 1, 4
- Intravascular catheter removal should be strongly considered in transplant patients with candidemia 1
Common Pitfalls and Caveats
- Azoles should not be used for treatment in patients who have received an azole for prophylaxis due to potential resistance 1
- Renal function must be monitored, as fluconazole is primarily cleared by renal excretion and dosage adjustments are necessary in patients with impaired renal function 2
- Drug interactions with immunosuppressive medications must be carefully monitored in transplant patients 5
- For truly refractory cases not responding to fluconazole, consider alternative antifungals such as voriconazole or an echinocandin 6