Management of Persistent Candidemia Despite Anidulafungin Treatment

Immediate Management Steps

The Infectious Diseases Society of America recommends removing central venous catheter if present, as this is a critical intervention for persistent candidemia 3, 4
Obtain follow-up blood cultures to document clearance and susceptibility testing to guide therapy, as recommended by the Clinical Infectious Diseases guidelines 5
Perform diagnostic workup to identify potential metastatic foci of infection, including dilated funduscopic examination to rule out endophthalmitis, as suggested by the Clinical Infectious Diseases guidelines 1, 2
Imaging of the genitourinary tract, liver, and spleen is recommended if blood cultures remain persistently positive, according to the Clinical Infectious Diseases guidelines 6

The Infectious Diseases Society of America recommends lipid formulation amphotericin B (3-5 mg/kg daily) as the most effective alternative for persistent candidemia 1, 2
Switching to a different echinocandin, such as caspofungin 150 mg daily or micafungin 150 mg daily, may be considered, as suggested by the Clinical Infectious Diseases guidelines 4
Combination therapy, adding a second antifungal from a different class, may be beneficial in refractory cases, according to the Clinical Infectious Diseases guidelines 3

For C. glabrata, lipid formulation amphotericin B is preferred when echinocandins have failed, as recommended by the Infectious Diseases Society of America 3, 5
For C. parapsilosis, consider switching to fluconazole (800 mg loading dose, then 400 mg daily) if susceptible, as suggested by the Clinical Infectious Diseases guidelines 2, 5
For C. krusei, use lipid formulation amphotericin B or voriconazole if echinocandin therapy has failed, according to the Clinical Infectious Diseases guidelines 1, 5

Continue antifungal therapy for at least 2 weeks after documented clearance of Candida from the bloodstream and resolution of symptoms, as recommended by the Infectious Diseases Society of America 1, 2
For cases with metastatic complications, longer therapy will be required based on the site of infection, according to the Clinical Infectious Diseases guidelines 5

In neutropenic patients with persistent candidemia, consider G-CSF–mobilized granulocyte transfusions if neutropenia is expected to be prolonged, as suggested by the Clinical Infectious Diseases guidelines 1, 2
For patients with suspected chronic disseminated (hepatosplenic) candidiasis, continue therapy until lesions resolve on repeat imaging, which typically takes several months, according to the Clinical Infectious Diseases guidelines 2, 5

Failure to remove central venous catheters is a common reason for persistent candidemia, as noted by the Infectious Diseases Society of America 3
Premature discontinuation of therapy before documented clearance can lead to relapse and persistent infection, according to the Clinical Infectious Diseases guidelines 1, 2
Failure to identify and address metastatic foci of infection (endocarditis, osteomyelitis, endophthalmitis) will result in persistent candidemia despite appropriate antifungal therapy, as suggested by the Clinical Infectious Diseases guidelines 6, 4

Obtain daily blood cultures until clearance is documented, as recommended by the Infectious Diseases Society of America 1
Monitor for drug toxicity, particularly with amphotericin B formulations, according to the Clinical Infectious Diseases guidelines 2
Repeat imaging studies if metastatic infection is suspected, as suggested by the Clinical Infectious Diseases guidelines 6