Management of Candida Infection in Critical Care Settings

Risk Assessment and Diagnosis

The Infectious Diseases Society of America recommends that empiric antifungal therapy should be considered in critically ill patients with risk factors for invasive candidiasis and no other known cause of fever 1
Risk factors for invasive candidiasis include Candida colonization, severity of illness, exposure to broad-spectrum antibiotics, recent major surgery, necrotizing pancreatitis, dialysis, parenteral nutrition, corticosteroids, and central venous catheters 1, 2
Daily bathing of ICU patients with chlorhexidine can decrease the incidence of bloodstream infections including candidemia 1, 3

The Infectious Diseases Society of America recommends echinocandin as the preferred empiric therapy for suspected invasive candidiasis, with a strong recommendation and moderate-quality evidence 1, 2
The American College of Clinical Pharmacy recommends the following dosing regimens for echinocandins: caspofungin 70 mg loading dose, then 50 mg daily; micafungin 100 mg daily; or anidulafungin 200 mg loading dose, then 100 mg daily 3
Fluconazole is an alternative therapy for patients with no recent azole exposure and not colonized with azole-resistant Candida species, with a recommended dosing regimen of 800 mg loading dose, then 400 mg daily 1, 2

The Infectious Diseases Society of America recommends a minimum of 2 weeks of antifungal therapy after documented clearance of Candida from the bloodstream for candidemia without metastatic complications 4, 7
For empiric therapy in patients who improve, the recommended duration is 2 weeks, the same as for documented candidemia 1, 2
For chronic disseminated candidiasis, antifungal therapy should be continued until lesions resolve on repeat imaging, which is usually several months 5, 6

The Infectious Diseases Society of America strongly recommends removal of central venous catheters in non-neutropenic patients with candidemia 7
For neutropenic patients, catheter removal should be considered on an individual basis, as sources other than the catheter may predominate 8
G-CSF-mobilized granulocyte transfusions can be considered in cases of persistent candidemia with anticipated protracted neutropenia 8

The Infectious Diseases Society of America recommends performing dilated funduscopic examinations to rule out endophthalmitis in patients with candidemia 8
For persistent candidemia, consider imaging of the genitourinary tract, liver, and spleen 7
Monitor for clinical response and clearance of Candida from the bloodstream 4

Delay in initiating appropriate antifungal therapy is associated with increased mortality, with mortality approaching 100% in patients with septic shock due to Candida without adequate source control or antifungal therapy within 24 hours 1, 2
Empiric therapy based solely on colonization with Candida species is inadequate 2
In ICUs with high rates of invasive candidiasis, fluconazole prophylaxis could be considered for high-risk patients 3