What is the recommended treatment for severe candidiasis in an adult?

Treatment of Severe Candidiasis in Adults

For severe candidiasis in adults, initiate an echinocandin (caspofungin 70 mg loading dose then 50 mg daily, micafungin 100 mg daily, or anidulafungin 200 mg loading dose then 100 mg daily) as first-line therapy, particularly for moderately severe to severe illness or recent azole exposure. 1

Initial Therapy Selection

The choice of initial antifungal depends on illness severity and prior azole exposure:

• Echinocandins are strongly preferred for:

  • Moderately severe to severe illness 1
  • Recent azole exposure 1
  • Neutropenic patients 1, 2
  • Critically ill patients 1

• Fluconazole (800 mg loading dose, then 400 mg daily) is acceptable only for:

  • Less critically ill patients 1, 2
  • No recent azole exposure 1, 2
  • Confirmed susceptible isolates (e.g., Candida albicans) 1, 2

• Amphotericin B formulations (deoxycholate 0.5-1.0 mg/kg daily or lipid formulation 3-5 mg/kg daily) are reserved for intolerance or limited availability of other antifungals 1

Species-Specific Considerations

Treatment must be adjusted based on the identified Candida species:

• Candida glabrata: Echinocandin is strongly preferred; do not transition to fluconazole or voriconazole without confirmed susceptibility 1

• Candida parapsilosis: Fluconazole is preferred, though continuing an echinocandin is reasonable if the patient is clinically improved with negative follow-up cultures 1

• Candida krusei: Use echinocandin, lipid formulation amphotericin B, or voriconazole (never fluconazole due to intrinsic resistance) 1

Step-Down Therapy

Transition from echinocandin to fluconazole (400 mg daily) is recommended when:

• Patient is clinically stable 1, 2
• Isolate is likely susceptible to fluconazole (e.g., C. albicans) 1, 2
• Blood cultures have cleared 1, 2

This de-escalation strategy is supported by the 2016 IDSA guidelines and allows for potential oral therapy completion 1, 2.

Duration and Monitoring

• Treatment duration: Continue for 2 weeks after documented clearance of Candida from bloodstream AND resolution of symptoms 1, 2

• Blood culture monitoring: Obtain daily or every other day until cultures no longer yield yeast 1, 2

• Ophthalmologic examination: Perform dilated fundoscopic exam within the first week for all non-neutropenic patients with candidemia 2

• Central venous catheter removal: Remove as early as possible when presumed to be the infection source 2

Critical Pitfalls to Avoid

Do not delay antifungal therapy: Initiate treatment within 24 hours of positive blood culture, as delays are associated with increased mortality 1

Do not use fluconazole empirically in severely ill patients: The 2016 IDSA guidelines explicitly favor echinocandins for this population based on superior outcomes 1

Do not prematurely discontinue therapy: This leads to relapse, particularly in chronic disseminated candidiasis 1, 2

Do not transition to azoles without susceptibility confirmation: Especially critical for C. glabrata and C. krusei 1

Evidence Quality Note

While the 2009 IDSA guidelines 1 established echinocandins as appropriate initial therapy, the 2016 update 1 strengthened the recommendation for echinocandins in severe disease with moderate-quality evidence. Recent research 3, 4 demonstrates non-inferiority between echinocandins, though one 2024 study 5 in immunocompromised/ICU patients found no difference between fluconazole and micafungin outcomes—however, this contradicts guideline recommendations and likely reflects that severity of illness, not drug choice, drove outcomes in their retrospective analysis. The guideline recommendation for echinocandins in severe disease remains the standard of care. 1