Treatment of Candida Overgrowth

Critical First Step: Determine If Treatment Is Needed

The Infectious Diseases Society of America recommends that Candida isolated from respiratory secretions almost always represents colonization and should NOT be treated with antifungals, even in ICU patients who are intubated or have chronic tracheostomies 1, 2
Autopsy studies consistently demonstrate that positive Candida cultures from respiratory secretions have poor predictive value for actual pneumonia—in one study, none of 77 ICU patients who died with positive BAL/sputum cultures had Candida pneumonia at autopsy 2
The American Urological Association suggests that asymptomatic candiduria in males does not require treatment unless the patient is neutropenic or undergoing urologic procedures 3
Growth of Candida from any site requires clinical correlation with signs and symptoms of actual infection before initiating therapy, as recommended by the Infectious Diseases Society of America 1, 4

The Infectious Diseases Society of America recommends that for candidemia and invasive candidiasis, echinocandins are now preferred first-line agents for critically ill patients, while fluconazole remains appropriate for less severely ill patients with susceptible species 1, 5
The recommended initial therapy options include echinocandins, such as caspofungin, micafungin, and anidulafungin, with specific dosing regimens 1, 5
The Infectious Diseases Society of America also recommends removing all central venous catheters if feasible, particularly in non-neutropenic patients and for C. parapsilosis infections 6
Therapy should be continued for 2 weeks AFTER documented clearance of Candida from bloodstream AND resolution of clinical signs, as recommended by the Infectious Diseases Society of America 1

The Infectious Diseases Society of America suggests that empiric antifungal therapy is indicated for patients with clinical evidence of intra-abdominal infection PLUS significant risk factors, such as recent abdominal surgery, anastomotic leaks, or necrotizing pancreatitis 1, 4
Source control with appropriate drainage and/or debridement is mandatory, as recommended by the Infectious Diseases Society of America 1, 4, 5
Antifungal choice follows the same algorithm as candidemia, with echinocandins for severe cases and fluconazole for susceptible species in stable patients, as recommended by the Infectious Diseases Society of America 1, 4

The Infectious Diseases Society of America recommends that asymptomatic candiduria rarely requires treatment, and removal of urinary catheters is often sufficient 8
For symptomatic cystitis or pyelonephritis, fluconazole is the first-line treatment, with a recommended dose of 200 mg daily for 7-14 days 3, 8
The Infectious Diseases Society of America also recommends removing or replacing urinary catheters and stents whenever possible 8

The Infectious Diseases Society of America recommends fluconazole as the first-line treatment for oropharyngeal candidiasis, with a loading dose of 200 mg, then 100 mg daily for at least 2 weeks 4, 5
For esophageal candidiasis, fluconazole is also the first-line treatment, with a loading dose of 200 mg, then 100-200 mg daily (up to 400 mg based on severity) 4
The Infectious Diseases Society of America recommends treating for a minimum of 3 weeks AND at least 2 weeks after symptom resolution for esophageal candidiasis 4

The American College of Obstetricians and Gynecologists suggests that uncomplicated cases of vulvovaginal candidiasis can be treated with a single dose of fluconazole 150 mg PO, or topical azoles intravaginally for 1-7 days 3
For recurrent vulvovaginal candidiasis, the American College of Obstetricians and Gynecologists recommends initial treatment with fluconazole 150 mg single dose, followed by maintenance therapy with fluconazole 150 mg weekly for 6 months 3

The Infectious Diseases Society of America recommends initial therapy with liposomal amphotericin B 3-5 mg/kg daily ± flucytosine 25 mg/kg four times daily, or high-dose echinocandin 1, 4, 5
Valve replacement is strongly recommended, and therapy should be continued for at least 6 weeks after surgery (longer if perivalvular abscess present) 1, 4

The Infectious Diseases Society of America recommends initial therapy with amphotericin B deoxycholate 1 mg/kg IV daily, or liposomal amphotericin B 5 mg/kg daily, with consideration of adding flucytosine 25 mg/kg four times daily for salvage therapy 1, 4, 5
Step-down therapy with fluconazole 12 mg/kg daily (800 mg) is recommended for susceptible isolates, and therapy should be continued until all signs, symptoms, CSF abnormalities, and radiological findings resolve 1, 4

The Infectious Diseases Society of America recommends empiric antifungal therapy for persistent fever despite 4-6 days of antibacterial therapy, with amphotericin B 0.5-0.7 mg/kg/day or liposomal amphotericin B 3 mg/kg/day 6
Therapy should be continued until resolution of neutropenia, as recommended by the Infectious Diseases Society of America 6

The American Academy of Pediatrics suggests that high-risk neonates in nurseries with >10% invasive candidiasis rates should receive fluconazole prophylaxis 3-6 mg/kg twice weekly, as recommended by the Infectious Diseases Society of America 1, 4