What is the recommended treatment for a patient suspected of having a Candida auris infection, particularly one with potential underlying health conditions such as immunosuppression or invasive medical devices?

Management of Candida auris Infection

For suspected or confirmed Candida auris infection, initiate an echinocandin immediately as first-line therapy, with specific dosing of caspofungin (70 mg loading dose, then 50 mg daily), micafungin (100 mg daily), or anidulafungin (200 mg loading dose, then 100 mg daily), as echinocandins remain the preferred agents despite emerging resistance patterns in this multidrug-resistant pathogen. 1, 2, 3

Initial Treatment Selection

• Echinocandins are the empiric drugs of choice for C. auris, particularly in critically ill patients, those with septic shock, immunosuppression, or invasive medical devices 1, 2, 3

• All three echinocandins (caspofungin, micafungin, anidulafungin) demonstrate comparable efficacy for invasive candidiasis, though approximately 5% of C. auris isolates show echinocandin resistance 4, 5

• Fluconazole should NOT be used empirically for C. auris, as approximately 90% of isolates demonstrate fluconazole resistance 5, 6

• Amphotericin B formulations are reserved as alternatives when echinocandin resistance is documented or suspected, though 30% of C. auris isolates show amphotericin B resistance 5, 7

Critical Management Steps

Source Control and Device Management

• Remove central venous catheters immediately in non-neutropenic patients with candidemia - this is a strong recommendation with moderate-quality evidence 1, 2

• For neutropenic patients, evaluate catheter removal individually, as other infection sources may predominate 2

• Remove or replace urinary catheters and other invasive devices when feasible, as C. auris readily colonizes these surfaces 5, 6

Susceptibility Testing

• Obtain antifungal susceptibility testing for all C. auris isolates immediately, testing for azole, echinocandin, and amphotericin B susceptibility 1

• Echinocandin susceptibility testing is particularly critical in patients with prior echinocandin exposure or when treating C. auris specifically 1

• Traditional biochemical methods frequently misidentify C. auris; use MALDI-TOF or molecular methods (PCR of ITS and D1/D2 regions) for accurate identification 5

Duration of Therapy

• Continue antifungal therapy for a minimum of 2 weeks after documented clearance of Candida from the bloodstream and resolution of attributable signs and symptoms 1, 2, 4

• For complicated infections with metastatic complications, extend therapy duration based on clinical response and repeat imaging 2

• Chronic disseminated candidiasis requires several months of therapy until lesions resolve on imaging 2

Monitoring Requirements

• Perform dilated funduscopic examination to rule out endophthalmitis in all patients with C. auris candidemia 1, 2

• Obtain imaging (CT or ultrasound) of genitourinary tract, liver, and spleen if blood cultures remain persistently positive 1, 2

• Monitor for clinical response and document negative blood cultures at least 24 hours apart before considering step-down therapy 8

Resistance and Alternative Therapies

• For echinocandin-resistant C. auris, consider high-dose echinocandin therapy (caspofungin 150 mg daily, micafungin 150 mg daily, or anidulafungin 200 mg daily) if susceptibility testing shows elevated but not fully resistant MICs 1

• Combination therapy or novel antifungals (ibrexafungerp, fosmanogepix) may be required for pan-resistant strains, though these represent salvage options 5, 7

• Lipid formulation amphotericin B (3-5 mg/kg daily) serves as an alternative when echinocandin resistance is documented, though clinical data specific to C. auris remain limited 1

Infection Control Imperatives

• Implement aggressive contact precautions immediately upon C. auris identification, as person-to-person transmission readily generates hospital outbreaks 5, 3, 6

• C. auris survives on inanimate surfaces for extended periods and resists commonly used disinfectants 5, 6

• Screen contacts and colonized patients, as colonization persists long after treatment and most colonized patients do not develop invasive infection 5, 6

• Enhanced environmental cleaning with appropriate disinfectants is essential to prevent transmission 6

Critical Pitfalls to Avoid

• Never delay echinocandin initiation while awaiting species identification in critically ill patients with suspected invasive candidiasis and risk factors 2, 9

• Do not use fluconazole empirically for suspected C. auris given the 90% resistance rate 5, 3

• Avoid premature step-down to azole therapy before confirming species identification, susceptibility results, and clinical stability 4

• Do not treat respiratory colonization with C. auris, as this typically represents colonization rather than true infection 1

• Failure to implement infection control measures promptly enables ongoing transmission and outbreak propagation 3, 6