What is the recommended treatment for a male patient with a catheter diagnosed with Candida parapsilosis?

Treatment of Candida parapsilosis Catheter-Related Bloodstream Infection

Remove the catheter immediately and initiate systemic antifungal therapy—this is mandatory for all Candida catheter-related infections, as catheter retention consistently increases mortality. 1, 2

Catheter Management

The catheter must be removed as early as possible in the course of infection. 1, 2

• For short-term catheters: Remove immediately and send the catheter tip for culture 1, 2
• For long-term catheters or implanted ports: Remove the device promptly, as all six prospective studies demonstrate that catheter retention worsens outcomes and increases mortality 1, 2
• If venous access is extremely limited (rare exception): Exchange the catheter over a guidewire temporarily and perform catheter cultures; if the same Candida species grows from the catheter tip as from blood cultures, the catheter must be removed 1, 2

Critical pitfall: Never delay catheter removal in an attempt to preserve venous access—this decision directly impacts survival 2

Systemic Antifungal Therapy

Initiate antifungal therapy immediately, even if symptoms resolve after catheter removal. 1, 2

First-Line Treatment for C. parapsilosis

Fluconazole 400 mg daily (or 6 mg/kg) is the preferred agent for C. parapsilosis catheter-related infections. 1

• C. parapsilosis is typically azole-susceptible, making fluconazole highly effective 1
• Loading dose: 800 mg on day 1, then 400 mg daily 1, 3
• Duration: 14 days after the first negative blood culture result 1, 2, 3

Alternative Agents

Echinocandins are reasonable alternatives but have higher MICs against C. parapsilosis compared to other Candida species: 1, 3

• Caspofungin: 70 mg loading dose, then 50 mg daily IV 1
• Micafungin: 100 mg daily IV 1, 4
• Anidulafungin: 200 mg loading dose, then 100 mg daily IV 1

Note: While echinocandins are effective, C. parapsilosis has inherently higher MICs to this drug class compared to other Candida species, making fluconazole the preferred choice when susceptibility is confirmed 3

Lipid formulation amphotericin B (3-5 mg/kg daily IV) is reserved for: 1

• Azole-resistant isolates
• Treatment failures
• Intolerance to other agents

Monitoring and Follow-Up

Obtain follow-up blood cultures every 24-48 hours until clearance is documented. 1, 2

• Document the exact time point when candidemia clears 1
• If candidemia persists beyond 72 hours of appropriate therapy, evaluate for complications 2

Perform dilated ophthalmological examination within the first week after diagnosis to rule out endophthalmitis 1

Evaluate for metastatic complications if persistent fungemia occurs: 2, 5

• Endocarditis (especially with prosthetic valves or prolonged candidemia) 5, 6
• Suppurative thrombophlebitis (suspect if fungemia persists beyond 3 days; confirm with CT or ultrasound) 2
• Endophthalmitis 1
• Septic emboli to spleen, vertebrae, or other organs 5

Duration of Therapy

Treat for 14 days after documented clearance of Candida from the bloodstream AND resolution of symptoms. 1, 2

• Never stop therapy before 14 days post-clearance, as premature discontinuation increases relapse risk 2
• The case literature demonstrates that inadequate treatment duration and failure to remove the source can lead to relapsing infection, development of resistance, and death 7, 5

Critical Pitfalls to Avoid

Do not retain the catheter under any circumstances except extreme venous access limitations—and even then, only temporarily. 1, 2 All prospective data show catheter retention worsens outcomes 1, 2

Do not assume symptom resolution after catheter removal means cure—systemic antifungal therapy is mandatory. 1, 2

Do not use suboptimal antifungal doses or discontinue therapy prematurely. 7 A documented case of C. parapsilosis candidemia treated with suboptimal doses and without source control resulted in development of fluconazole resistance and patient death 7

Do not use fluconazole empirically before confirming species identification and susceptibility, though C. parapsilosis is typically azole-susceptible 1, 2

Special Considerations

For patients with persistent or relapsing candidemia despite appropriate therapy: 7, 5

• Re-evaluate for retained catheter fragments or other intravascular foreign bodies
• Consider imaging for deep-seated infections (endocarditis, spondylodiscitis, abscesses)
• Repeat susceptibility testing, as resistance can emerge with prolonged infection and inadequate treatment 7