What are the differences in treatment approaches between the 2016 and 2025 candidiasis guidelines for immunocompetent and immunocompromised patients?

Key Differences Between 2016 and 2025 Candidiasis Guidelines

The 2025 guidelines do not exist in the provided evidence—only the 2016 IDSA guidelines are available, making a direct comparison impossible. However, I can clarify what the 2016 guidelines established and note that no substantive updates appear in the evidence provided.

What the 2016 IDSA Guidelines Established

For Candidemia and Invasive Candidiasis in Non-Neutropenic Adults

First-Line Therapy:

• Echinocandins became the preferred initial therapy (caspofungin 70 mg loading dose then 50 mg daily; micafungin 100 mg daily; anidulafungin 200 mg loading dose then 100 mg daily) for most patients 1
• Fluconazole 800 mg loading dose then 400 mg daily remains acceptable for selected patients who are not critically ill and unlikely to have fluconazole-resistant species 1

Step-Down Therapy:

• Transition from echinocandin to fluconazole within 5-7 days is recommended for clinically stable patients with susceptible isolates and negative repeat blood cultures 1

Duration:

• Treatment continues for 14 days after documented clearance of Candida from bloodstream and resolution of symptoms 1

For Neonates with Disseminated Candidiasis

• Amphotericin B deoxycholate 1 mg/kg daily is first-line 1
• Fluconazole 12 mg/kg daily is reasonable alternative in patients not on fluconazole prophylaxis 1
• Echinocandins should be used cautiously, limited to salvage therapy 1
• Duration is 2 weeks after clearance and symptom resolution 1

For Candida Pyelonephritis

Treatment Algorithm:

• Fluconazole-susceptible species: oral fluconazole 200-400 mg daily for 2 weeks 2
• Fluconazole-resistant C. glabrata: amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days with or without flucytosine 25 mg/kg four times daily 2
• C. krusei: amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1

Critical Adjunctive Measures:

• Elimination of urinary tract obstruction is mandatory 2
• Remove or replace nephrostomy tubes/stents when feasible 2

For Oropharyngeal Candidiasis

Mild Disease:

• Clotrimazole troches 10 mg five times daily OR miconazole mucoadhesive buccal 50 mg tablet once daily for 7-14 days 1
• Alternatives: nystatin suspension 4-6 mL four times daily OR nystatin pastilles 1-2 four times daily for 7-14 days 1

Moderate to Severe Disease:

• Oral fluconazole 100-200 mg daily for 7-14 days 1

Fluconazole-Refractory Disease:

• Itraconazole solution 200 mg once daily OR posaconazole suspension 400 mg twice daily for 3 days then 400 mg daily, up to 28 days 1
• Alternatives: voriconazole 200 mg twice daily OR amphotericin B deoxycholate oral suspension 100 mg/mL four times daily 1
• Intravenous echinocandin or IV amphotericin B deoxycholate 0.3 mg/kg daily for refractory cases 1

For Asymptomatic Candiduria

• Treatment is NOT recommended unless patient is neutropenic, very low-birth-weight infant (<1500 g), or undergoing urologic manipulation 1
• Catheter removal is strongly recommended when feasible 1

Important Diagnostic and Management Principles

Susceptibility Testing:

• Azole susceptibility testing recommended for all bloodstream and clinically relevant isolates 1
• Echinocandin susceptibility testing should be considered for patients with prior echinocandin exposure or infection with C. glabrata or C. parapsilosis 1

Central Venous Catheter Management:

• CVC removal strongly recommended for non-neutropenic patients when source is presumed to be the catheter 1
• Consider removal individually for neutropenic patients 1

Ophthalmologic Examination:

• Dilated fundoscopic exam recommended within first week for non-neutropenic patients 1
• For neutropenic patients, optimal timing is first week after neutrophil recovery 1

Why No 2025 Guidelines Exist in This Evidence

The most recent guidelines provided are from 2016 by the Infectious Diseases Society of America 1. Research articles from 2018 and 2024 discuss evolving epidemiology and emerging resistance patterns 3, 4, but these do not constitute formal guideline updates. The 2026 Praxis Medical Insights document 2 appears to summarize existing 2016 recommendations rather than introduce new guidelines.

The shift noted in recent literature includes:

• Increasing non-albicans species, particularly C. glabrata 3
• Emergence of C. auris as a concern 3, 4
• Growing fluconazole resistance in N. glabratus (formerly C. glabrata), C. parapsilosis, and C. auris 4
• Echinocandin resistance remains uncommon but requires monitoring 4