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Clinical Practice Guidelines for The Management of Candidiasis

Clinical Practice Guidelines for The Management of Candidiasis

Invasive infection due to Candida species is largely a condition associated with medical progress and is widely recognized as a major cause of morbidity and mortality in the healthcare environment.The Infectious Diseases Society of America (IDSA) issued a revised guideline, endorsed by American Academy of Pediatrics (AAP), the Pediatric Infectious Diseases Society (PIDS), and the Mycoses Study Group (MSG), for the treatment and management of Candida infections. Strong treatment recommendations for various  types of Candida infections are as follows :

  •  Treatment for Candidemia in Nonneutropenic Patients
  1. An echinocandin (caspofungin: loading dose 70 mg, then 50 mg daily; micafungin: 100 mg daily; anidulafungin: loading dose 200 mg, then 100 mg daily) is recommended as initial therapy (strong recommendation; high-quality evidence).
  2. As an alternative to echinocandin is fluconazole which can be used in patients who are not critically ill and are less-likely to have fluconazole-resistant Candida sps. Azole susceptibility testing for all blood-stream and echinocandin susceptibility testing is recommended in patients treated with echinocandin in the past and patients infected with C.glabrata and C.parapsilosi.
  3. In case of intolerance, limited availability, or resistance to other antifungal agents, a reasonable alternative is lipid formulation amphotericin B (AmB. Transition to fluconazole from AmB after 5-7 days is recommended in clinically stable patients, who have isolates that are susceptible to fluconazole and in whom repeat cultures on antifungal therapy is negative.A dilated ophthalmological examination needs to be done by an ophthalmologist within the first week of diagnosis of candidemia for all nonneutropenic patients. Blood culture should be repeated frequently, every 24 or 48 hours, to establish the time-point of clearance of candidemia.
  •  Removal of Central Venous Catheters in Nonneutropenic Patients

Central venous catheters (CVCs) should be removed as early as possible in the course of candidemia when the source is presumed to be the CVC and the catheter can be removed safely; this decision should be individualized for each patient (strong recommendation; moderate-quality evidence)

  • Treatment for Candidemia in Neutropenic Patients
  1. An echinocandin (caspofungin: loading dose 70 mg, then 50 mg daily; micafungin: 100 mg daily; anidulafungin: loading dose 200 mg, then 100 mg daily) is recommended as initial therapy (strong recommendation; moderate-quality evidence).Duration of therapy, without metastatic complications, is 2 weeks. The treatment is considered to be complete with the documented clearance of Candida sps from the bloodstream and resolution of neutropenia and candidemia symptoms.
  • Treatment for Chronic Disseminated (Hepatosplenic) Candidiasis
  1. Initial therapy with lipid formulation AmB, 3–5 mg/kg daily OR an echinocandin (micafungin: 100 mg daily; caspofungin: 70-mg loading dose, then 50 mg daily; or anidulafungin: 200-mg loading dose, then 100 mg daily), for several weeks is recommended, followed by oral fluconazole, 400 mg (6 mg/kg) daily, for patients who are unlikely to have a fluconazole-resistant isolate (strong recommendation; low-quality evidence).
  2. Infection may recur on premature discontinuation of antifungal therapy. Therefore, therapy should be continued until lesions resolve on repeat imaging, which usually takes several months.
  • Empiric Treatment for Suspected Invasive Candidiasis in Nonneutropenic Patients in ICU
  1. Empiric antifungal therapy should be considered in critically ill patients with risk factors for invasive candidiasis and no other known cause of fever and should be based on clinical assessment of risk factors, surrogate markers for invasive candidiasis, and/or culture data from nonsterile sites (strong recommendation; moderate-quality evidence). Empiric antifungal therapy should be started as soon as possible in patients who have the above risk factors and who have clinical signs of septic shock (strong recommendation; moderate-quality evidence).
  •  Prophylaxis to Prevent Invasive Candidiasis in the Intensive Care Unit Setting
  1. Fluconazole, 800-mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) daily, could be used in high-risk patients in adult ICUs with a high rate (>5%) of invasive candidiasis (weak recommendation; moderate-quality evidence).
  2. An alternative is to give an echinocandin (caspofungin: 70-mg loading dose, then 50 mg daily; anidulafungin: 200-mg loading dose and then 100 mg daily; or micafungin: 100 mg daily) (weak recommendation; low-quality evidence).
  • Treatment for Central Nervous System Infections in Neonates
  1. For neonates with disseminated candidiasis, AmB deoxycholate (1mg/kg daily) may be used.
  2. A preferable alternative in patients who have not been on fluconazole prophylaxis is fluconazole.
  • Treatment for Intra-abdominal Candidiasis
  • In all the patients having clinical evidence of intra-abdominal infection, empiric antifungal therapy may be used. The adequacy of source control and the clinical response would determine the duration of therapy.Treatment for Intra-abdominal Candidiasis
  • Empiric antifungal therapy should be considered for patients with clinical evidence of intra-abdominal infection and significant risk factors for candidiasis, including recent abdominal surgery, anastomotic leaks, or necrotizing pancreatitis (strong recommendation; moderate-quality evidence)
  • Treatment for Candida Intravascular Infections, including Endocarditis and Infections implantable Cardiac Devices
  1. Endocarditis is treated with lipid formulation AmB, with or without flucytosine, or high-dose echinocandin. A minimum of 6weeks of treatment should be followed after surgery or for a longer duration in patients with perivalvular abscesses and other complications. Valve replacement is recommended. For patients who cannot undergo valve replacement, long-term suppression with fluconazole may be followed.
  2. The entire device should be removed in pacemaker and implantable cardiac defibrillator infections. Antifungal therapy is the same as that recommended for native valve endocarditis.
  3. Suppurative Thrombophlebitis may need removal of catheter and incision and drainage or resection of the vein followed by intensive antifungal therapy.
  • Treatment for Candida Osteoarticular Infections
  1. Fluconazole, 400 mg (6 mg/kg) daily, for 6–12 months OR an echinocandin (caspofungin 50–70 mg daily, micafungin 100 mg daily, or anidulafungin 100 mg daily) for at least 2 weeks followed by fluconazole, 400 mg (6 mg/kg) daily, for 6–12 months is recommended (strong recommendation; low-quality evidence).Osteomyelitis treated with fluconazole or a for at least 2 weeks followed by fluconazole for 6–12 months. Surgical debridement is recommended in selected cases
  • Treatment for Candida Endophthalmitis
  1. All patients with candidemia should have a dilated retinal examination, preferably performed by an ophthalmologist, within the first week of therapy in nonneutropenic patients to establish if endophthalmitis is present (strong recommendation; low-quality evidence). For neutropenic patients, it is recommended to delay the examination until neutrophil recovery (strong recommendation; low-quality evidence).
  •     Treatment of Central Nervous System (CNS) Candidiasis
  1. For initial treatment, liposomal AmB, 5 mg/kg daily, with or without oral flucytosine, 25 mg/kg 4 times daily is recommended (strong recommendation; low-quality evidence). Therapy should continue until all signs and symptoms, and CSF and radiological abnormalities have resolved. Infected CNS devices, including ventriculostomy drains, shunts, stimulators, prosthetic reconstructive devices, and biopolymer wafers that deliver chemotherapy should be removed.
  • Treatment for Urinary Tract Infections Caused By Candida sps
  1. Elimination of predisposing factors, such as indwelling bladder catheters, is recommended whenever feasible (strong recommendation; low-quality evidence). Treatment with antifungal agents is NOT recommended unless the patient belongs to a group at high risk for dissemination; high-risk patients include neutropenic patients, very-low-birth-weight infants (<1500 g), and patients who will undergo urologic manipulation. Patients undergoing urologic procedures should be treated with oral fluconazole OR AmB deoxycholate, before and after the procedure.
  • Treatment for Vulvovaginal Candidiasis
  1. For the treatment of uncomplicated Candida vulvovaginitis, topical antifungal agents, with no one agent superior to another, are recommended (strong recommendation; high-quality evidence). Alternatively, a single oral dose of fluconazole may be used.
  • Treatment for Oropharyngeal Candidiasis
  1. For mild disease, clotrimazole troches, 10 mg 5 times daily, OR miconazole mucoadhesive buccal 50-mg tablet applied to the mucosal surface over the canine fossa once daily for 7–14 days are recommended (strong recommendation; high-quality evidence). Antiretroviral therapy is recommended to reduce the incidence of recurrent infections in HIV patients.
  • Treatment of Esophageal Candidiasis
  1. Systemic antifungal therapy is always required. A diagnostic trial of antifungal therapy is appropriate before performing an endoscopic examination (strong recommendation; high-quality evidence)A diagnostic trial of antifungal therapy should be performed before an endoscopic examination. Systemic antifungal therapy is always required.

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