What are the next steps for a patient with persistent candidemia despite treatment with anidulafungin (echinocandin antifungal)?

Management of Persistent Candidemia Despite Anidulafungin Treatment

For persistent candidemia despite anidulafungin treatment, switch to lipid formulation amphotericin B (3-5 mg/kg daily) or use combination therapy with another antifungal agent from a different class. 1

Immediate Management Steps

• Remove central venous catheter if present, as this is a critical intervention for persistent candidemia 1
• Obtain follow-up blood cultures to document clearance and susceptibility testing to guide therapy 1
• Perform diagnostic workup to identify potential metastatic foci of infection:
  • Dilated funduscopic examination to rule out endophthalmitis 1
  • Imaging of the genitourinary tract, liver, and spleen if blood cultures remain persistently positive 1

Antifungal Treatment Options

First-line alternatives when anidulafungin has failed:

• Lipid formulation amphotericin B (3-5 mg/kg daily) - recommended as the most effective alternative for persistent candidemia 1
• Switch to a different echinocandin - consider higher doses (caspofungin 150 mg daily, micafungin 150 mg daily) 1
• Combination therapy - adding a second antifungal from a different class may be beneficial in refractory cases 1

Species-specific considerations:

• For C. glabrata: Lipid formulation amphotericin B is preferred when echinocandins have failed 1
• For C. parapsilosis: Consider switching to fluconazole (800 mg loading dose, then 400 mg daily) if susceptible, as this species may have reduced susceptibility to echinocandins 1
• For C. krusei: Use lipid formulation amphotericin B or voriconazole if echinocandin therapy has failed 1

Duration of Therapy

• Continue antifungal therapy for at least 2 weeks after documented clearance of Candida from the bloodstream and resolution of symptoms 1
• For cases with metastatic complications, longer therapy will be required based on the site of infection 1

Additional Interventions

• In neutropenic patients with persistent candidemia, consider G-CSF–mobilized granulocyte transfusions if neutropenia is expected to be prolonged 1
• Evaluate for and address any underlying immunosuppression or predisposing conditions 2
• For patients with suspected chronic disseminated (hepatosplenic) candidiasis, continue therapy until lesions resolve on repeat imaging, which typically takes several months 1

Common Pitfalls and Caveats

• Failure to remove central venous catheters is a common reason for persistent candidemia 1, 3
• Inadequate dosing of antifungals can lead to treatment failure, particularly with echinocandins against certain species 4, 5
• Premature discontinuation of therapy before documented clearance can lead to relapse and persistent infection 1
• Failure to identify and address metastatic foci of infection (endocarditis, osteomyelitis, endophthalmitis) will result in persistent candidemia despite appropriate antifungal therapy 1

Monitoring Response

• Obtain daily blood cultures until clearance is documented 1
• Monitor for drug toxicity, particularly with amphotericin B formulations 1
• Repeat imaging studies if metastatic infection is suspected 1