What is the recommended first‑line treatment and management for Candida auris infection, including dosing, duration, source control, and infection‑control measures?

Candida auris: First-Line Treatment and Management

Echinocandins (caspofungin, micafungin, or anidulafungin) are the mandatory first-line therapy for all confirmed or suspected Candida auris infections, with fluconazole absolutely contraindicated due to >90% resistance rates. 1, 2, 3

Antifungal Therapy

First-Line Treatment (Strong Recommendation)

• Echinocandins are the drugs of choice with the following dosing regimens: 1, 2, 3
  • Caspofungin: 70 mg loading dose, then 50 mg daily (90% susceptibility) 1, 2
  • Micafungin: 100 mg daily (98.2% susceptibility) 1, 2
  • Anidulafungin: 200 mg loading dose, then 100 mg daily (97.2% susceptibility) 1, 2

Why Echinocandins Are Non-Negotiable

The susceptibility data makes this choice clear-cut: echinocandins maintain 90-98% activity against C. auris, while fluconazole shows only 10.7% susceptibility. 1, 2 This is fundamentally different from other Candida species where fluconazole remains a viable option for non-critically ill patients. 4

Second-Line Options (Only When Echinocandins Fail)

• Liposomal amphotericin B (3-5 mg/kg daily) or amphotericin B deoxycholate (0.5-1.0 mg/kg daily) may be considered for persistent candidemia or clinical unresponsiveness to echinocandins. 1, 2, 3
• Critical caveat: Only 43% of C. auris isolates are susceptible to amphotericin B, making this a suboptimal alternative that requires documented susceptibility testing before use. 1, 2, 3

Contraindicated Agents

• Fluconazole and itraconazole are absolutely contraindicated for C. auris due to >90% resistance rates. 1, 2, 3, 5
• This represents a major departure from standard candidemia management where fluconazole is acceptable for non-critically ill patients. 4

Treatment Duration

• Minimum 14 days after documented bloodstream clearance and resolution of clinical symptoms. 1, 2
• Obtain daily blood cultures until clearance is documented. 1
• Perform dilated funduscopic examination to rule out metastatic endophthalmitis. 4

Source Control

Central Venous Catheter Management

• Remove CVCs as early as safely possible when the catheter is the presumed source. 4, 1
• This recommendation is consistent with standard candidemia management but is particularly critical given C. auris's ability to form persistent biofilms on devices. 5, 6

Environmental Persistence

C. auris survives on inanimate surfaces for extended periods and forms "dry" biofilms that resist standard cleaning. 6 This makes source control more challenging than with other Candida species.

Infection Control Measures (Critical for Outbreak Prevention)

Patient Isolation and Screening

• Implement strict contact precautions for all confirmed or suspected C. auris cases with dedicated equipment. 1
• Screen high-risk patients and close contacts using composite swabs of axilla and groin. 1
• Patients require 3 consecutive negative screens at least 24 hours apart before being considered negative. 1
• Risk factors include prolonged ICU stay (>15-20 days), multiple antibiotics, invasive devices, and close contact with colonized patients. 7, 8, 9

Environmental Decontamination

• Use sporicidal disinfectants only: hydrogen peroxide, peracetic acid-based, or chlorine-based products. 1
• Quaternary ammonium compounds are ineffective against Candida species and should not be used. 1
• Standard hospital disinfectants commonly fail against C. auris, contributing to healthcare outbreaks. 5, 6

Laboratory Identification

• MALDI-TOF or molecular methods (PCR of ITS/D1-D2 regions) are required for accurate identification. 5
• Conventional biochemical tests frequently misidentify C. auris as C. haemulonii, C. famata, C. sake, or Saccharomyces cerevisiae. 7, 8
• Perform antifungal susceptibility testing on all isolates to confirm resistance patterns and guide therapy. 1, 3

Clinical Context and Mortality

C. auris carries mortality rates up to 64%, classifying it as an urgent public health threat. 1, 2, 3 The combination of multidrug resistance, environmental persistence, and person-to-person transmission in healthcare settings distinguishes it from other Candida species. 8, 6 Critically ill patients with multiple comorbidities in ICU settings are at highest risk. 7, 9, 6

Common Pitfalls to Avoid

• Never use fluconazole empirically when C. auris is suspected, even in non-critically ill patients—this contradicts standard candidemia guidelines but is essential for C. auris. 2, 3
• Do not rely on standard biochemical identification—demand molecular or MALDI-TOF confirmation. 5, 8
• Do not use standard hospital disinfectants—they are inadequate for C. auris environmental control. 1, 5
• Do not assume amphotericin B will work—57% of isolates are resistant, requiring susceptibility testing. 1, 2