What is the recommended treatment for candidemia?

Treatment of Candidemia

For candidemia in nonneutropenic adults, initiate treatment with an echinocandin (caspofungin 70 mg loading dose then 50 mg daily, anidulafungin 200 mg loading then 100 mg daily, or micafungin 100 mg daily) as first-line therapy, and always remove central venous catheters. 1

Initial Antifungal Selection

First-Line Therapy

• Echinocandins are the preferred initial treatment for candidemia in nonneutropenic patients due to their broad activity, safety profile, and superior outcomes in critically ill patients 1
• Specific dosing regimens 1:
  • Caspofungin: 70 mg loading dose, then 50 mg daily
  • Anidulafungin: 200 mg loading dose, then 100 mg daily
  • Micafungin: 100 mg daily
• Rezafungin (newer echinocandin) is now also recommended as first-line therapy 1

Alternative Agents

• Fluconazole (800 mg loading dose, then 400 mg daily) can be used in less critically ill patients who have not had prior azole exposure and when fluconazole-susceptible species are suspected 1
  • However, fluconazole resistance must be considered, particularly with prior azole exposure 1, 2
• Liposomal amphotericin B (3-5 mg/kg daily) is an alternative when echinocandins cannot be used 1
• Amphotericin B deoxycholate should be avoided due to severe side effects 1

Critical Management Steps

Source Control

• Central venous catheter removal is strongly recommended in all candidemia cases 1
• If catheters cannot be removed, prefer lipid-based amphotericin B or echinocandins over azoles 1

Evaluation for Metastatic Complications

• Perform dilated fundoscopy to detect endophthalmitis 1
• Consider transoesophageal echocardiography to rule out endocarditis 1
• Obtain imaging (CT or ultrasound) if blood cultures remain persistently positive 1

Treatment Duration and De-escalation

Duration

• Treat for minimum 14 days after documented clearance of Candida from bloodstream AND resolution of attributable signs/symptoms 1
• Obtain daily blood cultures until negativity is documented 1

Step-Down Therapy

• Switch to oral fluconazole (400 mg daily) after 10 days of IV therapy in clinically stable patients with fluconazole-susceptible isolates 1
• Switching is appropriate once patient has clinically improved and can tolerate oral intake 1

Special Populations

Neutropenic Patients

• Use similar echinocandin regimens as for nonneutropenic patients 1
• Consider higher intensity therapy (4 mg/kg voriconazole IV or equivalent) 1

Neonates

• Amphotericin B deoxycholate (1 mg/kg daily) is recommended as first-line 1
• Fluconazole (12 mg/kg IV/oral daily) is reasonable alternative in those without prior fluconazole prophylaxis 1
• Echinocandins should be used with caution and limited to salvage therapy in neonates 1
• Mandatory lumbar puncture and dilated retinal examination for all neonates with positive Candida cultures 1

ICU Patients Requiring Empiric Therapy

• In high-risk ICU patients with clinical sepsis and risk factors (recent abdominal surgery, broad-spectrum antibiotics, central lines, parenteral nutrition), start empiric antifungal therapy immediately 1
• Use same regimens as for documented candidemia 1

Common Pitfalls to Avoid

• Do not delay antifungal therapy while awaiting culture results in high-risk patients with septic shock 1
• Do not use fluconazole empirically in critically ill patients or those with prior azole exposure due to risk of resistant species 1, 2
• Do not assume Candida in respiratory secretions requires treatment—this usually represents colonization 1
• Do not stop therapy prematurely—ensure both blood culture clearance AND clinical resolution before discontinuing 1
• Do not forget to adjust doses in hepatic impairment (reduce maintenance doses of azoles) 3