Treatment of Candidemia
Initial Antifungal Selection
- The Infectious Diseases Society of America recommends echinocandins as the preferred initial treatment for candidemia in nonneutropenic patients due to their broad activity, safety profile, and superior outcomes in critically ill patients 1, 2, 3
- Specific dosing regimens for echinocandins include: caspofungin 70 mg loading dose, then 50 mg daily, anidulafungin 200 mg loading dose, then 100 mg daily, and micafungin 100 mg daily 1, 4
- Rezafungin, a newer echinocandin, is also recommended as first-line therapy for candidemia 3
- Fluconazole can be used in less critically ill patients who have not had prior azole exposure and when fluconazole-susceptible species are suspected, with a recommended dose of 800 mg loading dose, then 400 mg daily 1, 5
Critical Management Steps
- Central venous catheter removal is strongly recommended in all candidemia cases 1, 5, 6, 4, 7, 8
- Perform dilated fundoscopy to detect endophthalmitis 1, 5, 6, 4, 7
- Consider transoesophageal echocardiography to rule out endocarditis 2
Treatment Duration and De-escalation
- Treat for a minimum of 14 days after documented clearance of Candida from bloodstream and resolution of attributable signs/symptoms 1, 5, 6, 9, 4, 7
- Switch to oral fluconazole 400 mg daily after 10 days of IV therapy in clinically stable patients with fluconazole-susceptible isolates 1, 2
Special Populations
- In neonates, amphotericin B deoxycholate is recommended as first-line therapy, with a dose of 1 mg/kg daily 1, 5, 6, 4, 7, 8
- Echinocandins should be used with caution and limited to salvage therapy in neonates 1, 5, 6, 4, 7
- Mandatory lumbar puncture and dilated retinal examination are recommended for all neonates with positive Candida cultures 1, 5, 6, 4, 7, 8