What is the recommended management for Candida auris sepsis?

Management of Candida auris Sepsis

For Candida auris sepsis, echinocandins are the first-line treatment with anidulafungin (200 mg loading dose, then 100 mg daily), micafungin (100 mg daily), or caspofungin (70 mg loading dose, then 50 mg daily) strongly recommended due to high rates of azole resistance and the critical nature of this multidrug-resistant pathogen. 1

Initial Antifungal Selection

• Echinocandins are mandatory first-line therapy for C. auris candidemia, as this organism demonstrates extensive fluconazole resistance (only 10.7% susceptibility) and should be treated as azole-resistant until proven otherwise 1

• The susceptibility rates for C. auris to echinocandins are: caspofungin 90%, micafungin 98.2%, and anidulafungin 97.2%, making them the most reliable empiric choice 1

• Initiate antifungal therapy immediately upon suspicion of candidemia in critically ill patients with septic shock, as delays significantly increase mortality 2

Source Control Measures

• Central venous catheter removal is strongly recommended in all patients with C. auris candidemia, as this is critical for clearance 1

• Perform dilated funduscopic examination to rule out endophthalmitis in all patients with candidemia 2

• Obtain imaging (CT or ultrasound) of the genitourinary tract, liver, and spleen if blood cultures remain persistently positive 1

Alternative Therapy Options

• Liposomal amphotericin B (3-5 mg/kg daily) or amphotericin B deoxycholate may be considered if there is persistent candidemia or clinical unresponsiveness to echinocandins without evidence of amphotericin B resistance 1

• Amphotericin B susceptibility for C. auris is only 43.1%, making it a less reliable option but potentially useful for echinocandin-resistant strains 1

• Fluconazole should NOT be used empirically for C. auris given the 10.7% susceptibility rate, though it may be considered for step-down therapy only after documented susceptibility 1

Duration of Therapy

• Continue treatment for at least 14 days after documented clearance of Candida from the bloodstream and resolution of signs and symptoms attributable to candidemia 1, 2

• Repeat blood cultures to document clearance before considering discontinuation 1

Critical Monitoring Parameters

• Monitor for clinical response within 4-5 days; lack of improvement warrants susceptibility testing and potential therapy escalation 3

• Be vigilant for development of echinocandin resistance during therapy, as FKS1 mutations can emerge, particularly with prolonged treatment or persistent candiduria 4

• Perform repeat blood cultures every 48-72 hours until clearance is documented 1

Infection Control Considerations

• Implement strict contact precautions immediately as C. auris has extraordinary environmental persistence and transmission potential 5, 6

• Screen close contacts and roommates for colonization, as patient-to-patient transmission is well-documented 6

• Enhanced environmental cleaning with sporicidal agents is essential, as C. auris substantially contaminates the environment of colonized or infected patients 5

• Report all cases to public health authorities (CDC and state health departments) as this is a notifiable pathogen 7

Common Pitfalls to Avoid

• Never use fluconazole empirically for suspected C. auris - the resistance rate is too high (89.3%) to justify empiric use 1

• Do not delay echinocandin therapy while awaiting species identification - if C. auris is suspected based on epidemiologic factors (transfer from endemic areas, healthcare exposure), start echinocandins immediately 8, 6

• Be aware that C. auris is frequently misidentified as C. haemulonii, C. famata, C. sake, or Rhodotorula glutinis by automated systems, requiring confirmation with MALDI-TOF or ITS sequencing 4, 5

• Persistent candiduria may serve as a reservoir for recurrent candidemia, requiring prolonged antifungal therapy and consideration of urinary tract source control 4