Treatment of Systemic Candidiasis

Initial Treatment Selection

The Infectious Diseases Society of America recommends an echinocandin (caspofungin, micafungin, or anidulafungin) as the first-line treatment for most patients with systemic candidiasis, particularly those who are critically ill, have had recent azole exposure, or are at risk for fluconazole-resistant species 1
Caspofungin is recommended at a dose of 70 mg loading dose, then 50 mg daily, with a strength of evidence based on clinical trials 1, 2
Micafungin is recommended at a dose of 100 mg daily, with a strength of evidence based on clinical trials 1
Anidulafungin is recommended at a dose of 200 mg loading dose, then 100 mg daily, with a strength of evidence based on clinical trials 1

For C. glabrata infections, an echinocandin is strongly preferred, with liposomal amphotericin B (3-5 mg/kg daily) as an alternative, based on evidence from clinical studies 2
For C. parapsilosis infections, fluconazole or liposomal amphotericin B is preferred as initial therapy, with continuation of echinocandin reasonable if already receiving and clinically stable, based on evidence from clinical studies 2
For C. krusei infections, an echinocandin, liposomal amphotericin B, or voriconazole is recommended, based on evidence from clinical studies 2

Removal of all central venous catheters is strongly recommended for all patients with candidemia, as it significantly impacts outcomes, based on evidence from clinical studies 1, 3
Susceptibility testing for azole is mandatory for all bloodstream and clinically relevant Candida isolates, with echinocandin susceptibility testing considered in patients with prior echinocandin exposure or infections with C. glabrata or C. parapsilosis, based on evidence from clinical studies 1

Treatment should continue for 2 weeks after documented clearance of Candida from the bloodstream, resolution of symptoms attributable to candidemia, and resolution of neutropenia (if applicable), based on evidence from clinical studies 2

Liposomal amphotericin B (3-5 mg/kg daily) is recommended for patients with intolerance to echinocandins or limited availability of other antifungals, with a strength of evidence based on clinical trials 2, 4
Voriconazole can be used when additional mold coverage is desired, based on evidence from clinical studies 2

The Infectious Diseases Society of America recommends against relying on fluconazole as first-line in critically ill patients, as echinocandins have superior outcomes in this population, based on evidence from clinical studies 1
The Infectious Diseases Society of America recommends against leaving central venous catheters in place, as catheter retention significantly worsens outcomes, based on evidence from clinical studies 1, 3
The Infectious Diseases Society of America recommends against using azoles empirically in patients who received azole prophylaxis, as resistance is likely, based on evidence from clinical studies 2
The Infectious Diseases Society of America recommends against stopping therapy prematurely, ensuring a full 2-week course after blood culture clearance, based on evidence from clinical studies 2
The Infectious Diseases Society of America recommends against assuming all Candida species have the same susceptibility, as species identification and susceptibility testing are essential, based on evidence from clinical studies 1