What is the treatment for Candida auris infection?

Treatment of Candida auris Infection

Echinocandins (caspofungin, micafungin, or anidulafungin) are the strongly recommended first-line therapy for all C. auris infections, with susceptibility rates of 90-98.2%. 1, 2

First-Line Treatment Regimen

• Initiate echinocandin therapy immediately upon identification or strong suspicion of C. auris infection 1, 2
• Standard dosing: caspofungin 70 mg loading dose then 50 mg daily; anidulafungin 200 mg loading dose then 100 mg daily; or micafungin 100 mg daily 3
• Do NOT use fluconazole for C. auris - only 10.7% of isolates are susceptible, making it inappropriate even for non-critically ill patients 1, 2, 3
• Continue treatment for at least 14 days after documented clearance from bloodstream and complete resolution of symptoms 1, 2

Alternative Therapy for Echinocandin Failure

If candidemia persists or clinical response is inadequate despite echinocandin therapy:

• Switch to liposomal amphotericin B (5 mg/kg daily) or amphotericin B deoxycholate (1 mg/kg daily) only if susceptibility testing confirms no resistance 1, 2, 3
• Be aware that C. auris shows only 43.1% overall susceptibility to amphotericin B, making this a less reliable option 1, 2, 3
• For CNS or epidural involvement, consider adding flucytosine (25 mg/kg orally four times daily) to amphotericin B, with therapeutic drug monitoring targeting serum levels of 40-60 mg/mL 3
• Never use flucytosine as monotherapy due to rapid resistance emergence 3

Critical Management Steps

Diagnostic and monitoring requirements:

• Obtain daily blood cultures until clearance is documented 2
• Perform antifungal susceptibility testing on all isolates to confirm resistance patterns 2
• Remove all indwelling catheters and devices 3
• Conduct diagnostic workup for metastatic foci if blood cultures remain positive 2

Infection control measures (essential to prevent transmission):

• Implement strict patient isolation immediately 2
• Screen high-risk patients and close contacts using composite swabs of axilla and groin 2
• Use sporicidal disinfectants (hydrogen peroxide, peracetic acid-based, or chlorine-based) for environmental cleaning - quaternary ammonium compounds are ineffective 2
• Consider patients negative only after 3 consecutive negative screens taken at least 24 hours apart 2

Site-Specific Considerations

• Bloodstream infections: Echinocandins remain first-line 1, 2
• CNS/epidural infections: Urgent surgical debridement plus liposomal amphotericin B with flucytosine 3
• Urinary tract fungus balls: Surgical intervention required in addition to antifungal therapy 1, 2

Critical Pitfalls to Avoid

• Never delay treatment waiting for species identification - C. auris is often misidentified by conventional methods, requiring MALDI-TOF or molecular techniques for accurate diagnosis 4, 5
• Resistance can emerge during therapy - approximately 5% of isolates develop echinocandin resistance, and pan-resistant strains have been documented in New York and other locations 6, 5
• C. auris persists in healthcare environments and can colonize patients indefinitely, making transmission control as important as treatment 4, 7
• The mortality rate reaches up to 64%, underscoring the urgency of appropriate initial therapy 1, 2