Duration of Micafungin Therapy for Candidemia
Treat with micafungin for a minimum of 14 days after the first negative blood culture and complete resolution of all symptoms attributable to candidemia. 1
Standard Treatment Duration
The Infectious Diseases Society of America (IDSA) recommends 2 weeks of therapy after documented clearance of Candida from the bloodstream AND resolution of symptoms. 1
Follow-up blood cultures must be performed daily or every other day to establish the exact time point when candidemia has cleared. 1
The 14-day clock starts only after BOTH conditions are met: negative blood cultures AND symptom resolution (fever, hemodynamic instability resolved). 1
Special Populations Requiring Extended Duration
Neutropenic Patients
Treat for 2 weeks after documented bloodstream clearance, resolution of symptoms, AND resolution of neutropenia (absolute neutrophil count >500 cells/μL). 1, 2
The neutropenia must resolve before stopping therapy, which may extend treatment well beyond 14 days. 1, 2
Neonates
Treat for a minimum of 3 weeks from clinical improvement due to higher risk of disseminated disease. 1, 2
Perform lumbar puncture and ophthalmoscopic examination in all neonates with positive blood or urine cultures for Candida. 1
Image the genitourinary tract, liver, and spleen if blood cultures remain persistently positive. 1
When Blood Cultures Cannot Be Performed
Treat for a minimum of 14 days from when the patient becomes clinically stable and completely asymptomatic. 2
Base treatment duration entirely on clinical parameters: complete resolution of fever, hemodynamic stability, normalization of leukocytosis, and resolution of any organ-specific symptoms. 2
Be more conservative without blood culture confirmation—ensure the full 14 days after complete clinical resolution. 2
Essential Concurrent Interventions
Central Venous Catheter Management
Remove all central venous catheters as early as safely possible during the course of candidemia. 1
Catheter retention significantly worsens outcomes and may prolong required treatment duration. 2
Ophthalmologic Examination
All patients must have a dilated funduscopic examination within the first week after diagnosis. 1, 2
This examination is mandatory because 16% of candidemia patients have ocular involvement (endophthalmitis), which requires extended therapy duration (4-6 weeks). 1, 2
For neutropenic patients, delay the examination until after neutrophil recovery, as findings are minimal during neutropenia. 1
Imaging for Metastatic Complications
Consider imaging (genitourinary tract, liver, spleen) if fever persists beyond 72 hours of appropriate therapy or if localizing symptoms develop. 2
Metastatic complications require significantly longer treatment duration (often months for chronic disseminated candidiasis). 1
Micafungin Dosing
Alternative dose: 150 mg daily may be considered, though outcomes are comparable to 100 mg daily. 3, 4
Loading doses are not required for micafungin (unlike caspofungin or anidulafungin). 1
Common Pitfalls to Avoid
Do not stop therapy at 7-10 days just because the patient appears improved—complete the full 14-day course after documented clearance and symptom resolution. 2
Do not count treatment days from the start of therapy—the 14-day minimum begins only after blood cultures are negative and symptoms have resolved. 1, 2
Do not skip the ophthalmologic examination—this is the only way to detect endophthalmitis that would require 4-6 weeks of therapy instead of 2 weeks. 2
Do not assume clinical improvement equals bloodstream clearance—obtain follow-up blood cultures to document clearance. 1
Step-Down Therapy Considerations
For patients with fluconazole-susceptible isolates (e.g., Candida albicans) who are clinically stable with documented bloodstream clearance, transition to fluconazole 400 mg daily is appropriate. 1
This step-down approach does not change the total duration requirement—still treat for 14 days total after clearance and symptom resolution. 1