Management of Candidiasis

Publication Date: December 16, 2015
Last Updated: November 8, 2022

Management

I. Candidemia in Non-Neutropenic Patients

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. ( S/H )
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Fluconazole intravenous or oral, 800 mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) daily is an acceptable alternative to an echinocandin as initial therapy in selected patients, including those who are not critically ill and who are considered unlikely to have a fluconazole resistant Candida species. ( S/H )
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Testing for azole susceptibility is recommended for all bloodstream and other clinically relevant Candida isolates. Testing for echinocandin susceptibility should be considered in patients who have had prior treatment with an echinocandin and among those who have infection with C. glabrata or C. parapsilosis. ( S/L )
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Transition from an echinocandin to fluconazole (usually within 5-7 days) is recommended for patients who are clinically stable, have isolates that are susceptible to fluconazole (e.g., C. albicans), and have negative repeat blood cultures following initiation of antifungal therapy. ( S/M )
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For infection due to C. glabrata, transition to higher-dose fluconazole 800 mg (12 mg/kg) daily or voriconazole 200-300 mg (3-4 mg/kg) twice daily should be considered only among patients with fluconazole-susceptible or voriconazole-susceptible isolates. ( S/L )
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Lipid formulation amphotericin B (AmB) (3-5 mg/kg daily) is a reasonable alternative if there is intolerance, limited availability, or resistance to other antifungal agents. ( S/H )
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Transition from AmB to fluconazole is recommended after 5-7 days among patients who have isolates that are susceptible to fluconazole, who are clinically stable, and in whom repeat cultures on antifungal therapy are negative. ( S/H )
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Among patients with suspected azole and echinocandin-resistant Candida infections, lipid formulation AmB (3-5 mg/kg/d) is recommended. ( S/L )
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Voriconazole 400 mg (6 mg/kg) twice daily for 2 doses, then 200 mg (3 mg/kg) twice daily is effective for candidemia but offers little advantage over fluconazole as initial therapy. ( S/M )
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Voriconazole is recommended as step-down oral therapy for selected cases of candidemia due to C. krusei. ( S/L )
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All non-neutropenic patients with candidemia should have a dilated ophthalmological examination, preferably performed by an ophthalmologist, within the first week after diagnosis. ( S/L )
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Follow-up blood cultures should be performed every day or every other day to establish the time point at which candidemia has been cleared. ( S/L )
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Recommended duration of therapy for candidemia without obvious metastatic complications is for 2 weeks after documented clearance of Candida species from the bloodstream and resolution of symptoms attributable to candidemia. ( S/M )
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II. Central Venous Catheters (CVCs) in Non-Neutropenic Patients with Candidemia

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. ( S/M )
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III. Candidemia in Neutropenic Patients

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. ( S/M )
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Lipid formulation AmB, 3-5 mg/kg daily, is an effective but less attractive alternative because of the potential for toxicity. ( S/M )
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Fluconazole, 800 mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) daily, is an alternative for patients who are not critically ill and have had no prior azole exposure. ( W/L )
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Fluconazole, 400 mg (6 mg/kg) daily, can be used for step-down therapy during persistent neutropenia in clinically stable patients who have susceptible isolates and documented bloodstream clearance. ( W/L )
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Voriconazole, 400 mg (6 mg/kg) twice daily for 2 doses, then 200-300 mg (3-4 mg/kg) twice daily, can be used in situations in which additional mold coverage is desired. ( W/L )
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Voriconazole can also be used as step-down therapy during neutropenia in clinically stable patients who have had documented bloodstream clearance and isolates that are susceptible to voriconazole. ( W/L )
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For infections due to C. krusei, an echinocandin, lipid formulation AmB or voriconazole is recommended. ( S/L )
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Recommended minimum duration of therapy for candidemia without metastatic complications is 2 weeks after documented clearance of Candida from the bloodstream, provided neutropenia and symptoms attributable to candidemia have resolved. ( S/L )
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Ophthalmological findings of choroidal and vitreal infection are minimal until recovery from neutropenia. Therefore, dilated fundoscopic examinations should be performed within the first week after recovery from neutropenia. ( S/L )
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In the neutropenic patient, sources of candidiasis other than a central venous catheter (e.g., gastrointestinal tract) predominate. Catheter removal should be considered on an individual basis. ( S/L )
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G-CSF-mobilized granulocyte transfusions can be considered in cases of persistent candidemia with anticipated protracted neutropenia. ( W/L )
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IV. Chronic Disseminated (Hepatosplenic) Candidiasis

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. ( S/L )
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Therapy should continue until lesions resolve on repeat imaging, which is usually several months. Premature discontinuation of antifungal therapy can lead to relapse. ( S/L )
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If chemotherapy or hematopoietic cell transplantation is required, it should not be delayed because of the presence of chronic disseminated candidiasis, and antifungal therapy should be continued throughout the period of high risk to prevent relapse. ( S/L )
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For patients who have debilitating persistent fevers, short term (1-2 weeks) treatment with non-steroidal anti-inflammatory drugs or corticosteroids can be considered. ( W/L )
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V. Empirical Treatment for Suspected Invasive Candidiasis in Non-Neutropenic Patients in the Intensive Care Unit (ICU)

Empirical 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 non-sterile sites. ( S/M )
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Empirical 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. ( S/M )
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Preferred empirical therapy for suspected candidiasis in non-neutropenic patients in the ICU is an echinocandin (caspofungin, loading dose of 70 mg, then 50 mg daily; micafungin, 100 mg daily; anidulafungin, loading dose of 200 mg, then 100 mg daily). ( S/M )
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Fluconazole, 800 mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) daily, is an acceptable alternative for patients who have had no recent azole exposure and are not colonized with azole resistant Candida species. ( S/M )
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Lipid formulation AmB, 3-5 mg/kg daily, is an alternative if there is intolerance to other antifungal agents. ( S/L )
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Recommended duration of empirical therapy for suspected invasive candidiasis in those patients who improve is 2 weeks, the same as for treatment of documented candidemia. ( W/L )
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For patients who have no clinical response to empirical antifungal therapy at 4-5 days and who do not have subsequent evidence of invasive candidiasis after the start of empirical therapy or have a negative non-culture-based diagnostic assay with a high negative predictive value, consideration should be given to stopping antifungal therapy. ( S/L )
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VI. Prophylaxis to Prevent Invasive Candidiasis in the ICU Setting

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. ( W/M )
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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). ( W/L )
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Daily bathing of ICU patients with chlorhexidine, which has been shown to decrease the incidence of bloodstream infections including candidemia, could be considered. ( W/M )
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VII. Neonatal Candidiasis, including Central Nervous System Infection

Invasive Candidiasis and Candidemia

AmB deoxycholate, 1 mg/kg daily, is recommended for neonates with disseminated candidiasis. ( S/M )
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Fluconazole, 12 mg/kg IV or oral daily, is a reasonable alternative in patients who have not been on fluconazole prophylaxis. ( S/M )
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Lipid formulation AmB, 3-5 mg/kg daily, is an alternative, but should be used with caution, particularly in the presence of urinary tract involvement. ( W/L )
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Echinocandins should be used with caution and generally limited to salvage therapy or to situations in which resistance or toxicity preclude the use of AmB deoxycholate or fluconazole. ( W/L )
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A lumbar puncture and a dilated retinal examination are recommended in neonates with cultures positive for Candida species from blood and/or urine. ( S/L )
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CT or ultrasound imaging of the genitourinary tract, liver, and spleen should be performed if blood cultures are persistently positive for Candida spp. ( S/L )
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Central venous catheter removal is strongly recommended. ( S/M )
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The recommended duration of therapy for candidemia without obvious metastatic complications is for 2 weeks after documented clearance of Candida species from the bloodstream and resolution of signs attributable to candidemia. ( S/L )
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CNS infections in Neonates

For initial treatment, AmB deoxycholate, 1 mg/kg IV daily, is recommended. ( S/L )
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An alternative regimen is liposomal AmB, 5 mg/kg daily. ( S/L )
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The addition of flucytosine, 25 mg/kg 4 times daily, may be considered as salvage therapy in patients who have not had a clinical response to initial AmB therapy, but adverse effects are frequent. ( W/L )
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For step-down treatment after the patient has responded to initial treatment, fluconazole, 12 mg/kg daily, is recommended for isolates that are susceptible to fluconazole. ( S/L )
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Therapy should continue until all signs, symptoms, and CSF and radiological abnormalities, if present, have resolved. ( S/L )
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Infected CNS devices, including ventriculostomy drains and shunts, should be removed if at all possible. ( S/L )
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Prophylaxis in the Neonatal ICU Setting

In nurseries with high rates (>10%) of invasive candidiasis, intravenous or oral fluconazole prophylaxis, 3-6 mg/kg twice weekly for 6 weeks, in neonates with birth weights <1000 g is recommended. ( S/H )
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Oral nystatin, 100,000 units 3 times daily for 6 weeks, is an alternative to fluconazole in neonates with birth weights <1500 g in situations in which availability or resistance preclude the use of fluconazole. ( W/M )
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Oral bovine lactoferrin (100 mg/day) may be effective in neonates <1500 g but is not currently available in U.S. hospitals. ( W/M )
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VIII. Intra-Abdominal Candidiasis

Empirical 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. ( S/M )
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Treatment of intra-abdominal candidiasis should include source control, with appropriate drainage and/or debridement. ( S/M )
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The choice of antifungal therapy is the same as for the treatment of candidemia or empirical therapy for non-neutropenic patients in the ICU (See Sections I and V). ( S/M )
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The duration of therapy should be determined by adequacy of source control and clinical response. ( S/L )
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IX. Candida Species in the Respiratory Tract

Growth of Candida from respiratory secretions usually indicates colonization and rarely requires treatment with antifungal therapy. ( S/M )
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X. Candida Intravascular Infections, Including Endocarditis and Infections of Implantable Cardiac Devices

Candida Endocarditis

For native valve endocarditis, lipid formulation AmB, 3-5 mg/kg daily, with or without flucytosine, 25 mg/kg 4 times daily, OR high-dose echinocandin (caspofungin, 150 mg daily, micafungin, 150 mg daily, or anidulafungin, 200 mg daily) is recommended for initial therapy. ( S/L )
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Step-down therapy to fluconazole, 400-800 mg (6-12 mg/kg) daily, is recommended for patients who have susceptible Candida isolates, have demonstrated clinical stability, and have cleared Candida from the bloodstream. ( S/L )
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Oral voriconazole, 200-300 mg (3-4 mg/kg) twice daily, or posaconazole tablets, 300 mg daily, can be used as step down
therapy for isolates that are susceptible to those agents but not susceptible to fluconazole. ( W/VL )
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Valve replacement is recommended. Treatment should continue for ≥6 weeks after surgery and for a longer duration in patients with perivalvular abscesses and other complications. ( S/L )
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For patients who cannot undergo valve replacement, long-term suppression with fluconazole, 400-800 mg (6-12 mg/kg) daily, if the isolate is susceptible, is recommended. ( S/L )
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For prosthetic valve endocarditis, the same antifungal regimens suggested for native valve endocarditis are recommended. ( S/L )
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Chronic suppressive antifungal therapy with fluconazole, 400-800 mg (6-12 mg/kg) daily, is recommended to prevent recurrence. ( S/L )
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Candida Infection of Implantable Cardiac Devices

For pacemaker and implantable cardiac defibrillator infections, the entire device should be removed. ( S/M )
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Antifungal therapy is the same as that recommended for native valve endocarditis. ( S/L )
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For infections limited to generator pockets, 4 weeks of antifungal therapy after removal of the device is recommended. ( S/L )
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For infections involving the wires, ≥6 weeks of antifungal therapy after wire removal is recommended. ( S/L )
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For ventricular assist devices that cannot be removed, the antifungal regimen is the same as that recommended for native valve endocarditis. ( S/L )
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Chronic suppressive therapy with fluconazole if the isolate is susceptible, for as long as the device remains in place, is recommended. ( S/L )
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Candida Suppurative Thrombophlebitis

Catheter removal and incision and drainage or resection of the vein, if feasible, is recommended. ( S/L )
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Lipid formulation AmB, 3-5 mg/kg daily, OR fluconazole, 400-800 mg (6-12 mg/kg) daily, OR an echinocandin (caspofungin, 150 mg daily, micafungin, 150 mg daily, or anidulafungin, 200 mg daily) for ≥2 weeks after candidemia (if present) has cleared is recommended. ( S/L )
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Step-down therapy to fluconazole, 400-800 mg (6-12 mg/kg) daily, should be considered for patients who have initially responded to AmB or an echinocandin, are clinically stable, and have a fluconazole-susceptible isolate. ( S/L )
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Resolution of the thrombus can be used as evidence to discontinue antifungal therapy if clinical and culture data are supportive. ( S/L )
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XI. Candida Osteoarticular Infections

Candida Osteomyelitis

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 ≥2 weeks followed by fluconazole, 400 mg (6 mg/kg) daily, for 6-12 months is recommended. ( S/L )
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Lipid formulation AmB, 3-5 mg/kg daily, for ≥2 weeks followed by fluconazole, 400 mg (6 mg/kg) daily, for 6-12 months is a less attractive alternative. ( W/L )
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Surgical debridement is recommended in selected cases. ( S/L )
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Candida Septic Arthritis

Fluconazole, 400 mg (6 mg/kg) daily, for 6 weeks OR an echinocandin (caspofungin 50-70 mg daily, micafungin 100 mg daily, or anidulafungin 100 mg daily) for 2 weeks followed by fluconazole, 400 mg (6 mg/kg) daily, for ≥4 weeks is recommended. ( S/L )
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Lipid formulation AmB, 3-5 mg/kg daily, for 2 weeks, followed by fluconazole, 400 mg (6 mg/kg) daily, for ≥4 weeks is a less attractive alternative. ( W/L )
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Surgical drainage is indicated in all cases of septic arthritis. ( S/M )
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For septic arthritis involving a prosthetic device, device removal is recommended. ( S/M )
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If the prosthetic device cannot be removed, chronic suppression with fluconazole, 400 mg (6 mg/kg) daily, if the isolate is susceptible, is recommended. ( S/L )
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XII. Candida Endophthalmitis

General Approach to Candida Endophthalmitis

All patients with candidemia should have a dilated retinal examination, preferably performed by an ophthalmologist, within the first week of therapy in non-neutropenic patients to establish if endophthalmitis is present. ( S/L )
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For neutropenic patients it is recommended to delay the examination until neutrophil recovery. ( S/L )
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The extent of ocular infection (chorioretinitis with or without macular involvement and with or without vitritis) should be determined by an ophthalmologist. ( S/L )
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Decisions regarding antifungal treatment and surgical intervention should be made jointly by an ophthalmologist and an infectious diseases physician. ( S/L )
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Candida Chorioretinitis WITHOUT Vitritis

For fluconazole/voriconazole susceptible isolates, fluconazole, loading dose, 800 mg (12 mg/kg), then 400-800 mg (6-12 mg/kg) daily OR voriconazole, loading dose 400 mg (6 mg/kg) IV twice daily for 2 doses, then 300 mg (4 mg/kg) IV or oral twice daily is recommended. ( S/L )
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For fluconazole/voriconazole resistant isolates, liposomal AmB, 3-5 mg/kg IV daily, with or without oral flucytosine, 25 mg/kg 4 times daily is recommended. ( S/L )
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With macular involvement, antifungal agents as noted above PLUS intravitreal injection of either AmB deoxycholate, 5-10 μg/0.1 mL
sterile water, or voriconazole, 100 μg/0.1 mL sterile water or normal saline, to ensure a prompt high level of antifungal activity is recommended. ( S/L )
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The duration of treatment should be at least 4-6 weeks, with the final duration depending on resolution of the lesions as determined by repeated ophthalmological examinations. ( S/L )
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Candida Chorioretinitis WITH Vitritis

Antifungal therapy as detailed above for chorioretinitis without vitritis, PLUS intravitreal injection of either AmB deoxycholate, 5-10 μg/0.1 mL
sterile water, or voriconazole, 100 μg/0.1 mL sterile water or normal saline is recommended. ( S/L )
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Vitrectomy should be considered to decrease the burden of organisms and to allow the removal of fungal abscesses that are inaccessible to systemic antifungal agents. ( S/L )
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The duration of treatment should be ≥4-6 weeks, with the final duration dependent on resolution of the lesions as determined by repeated ophthalmological examinations. ( S/L )
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XIII. Central Nervous System (CNS) Candidiasis

For initial treatment, liposomal AmB, 5 mg/kg daily, with or without oral flucytosine, 25 mg/kg 4 times daily is recommended. ( S/L )
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For step-down therapy after the patient has responded to initial treatment, fluconazole, 400-800 mg (6-12 mg/kg) daily, is recommended. ( S/L )
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Therapy should continue until all signs and symptoms, cerebrospinal fluid and radiological abnormalities have resolved. ( S/L )
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Infected CNS devices, including ventriculostomy drains, shunts, stimulators, prosthetic reconstructive devices, and biopolymer wafers that deliver chemotherapy, should be removed if possible. ( S/L )
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For patients in whom a ventricular device cannot be removed, AmB deoxycholate could be administered through the device into the ventricle at a dosage ranging from 0.01 mg to 0.5 mg in 2 mL 5% dextrose in water. ( W/L )
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XIV. Urinary Tract Infections Due to Candida Species

Asymptomatic Candiduria

Elimination of predisposing factors, such as indwelling bladder catheters, is recommended whenever feasible. ( S/L )
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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 grams), and patients who will undergo urologic manipulation. ( S/L )
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Neutropenic patients and very low birth weight infants should be treated as recommended for candidemia [see Sections III and VII. ( S/L )
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Patients undergoing urologic procedures should be treated with oral fluconazole, 400 mg (6 mg/kg) daily, OR AmB deoxycholate, 0.3-0.6 mg/kg daily, for several days before and after the procedure. ( S/L )
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Symptomatic Candida Cystitis

For fluconazole-susceptible organisms, oral fluconazole, 200 mg (3 mg/kg) daily for 2 weeks is recommended. ( S/M )
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For fluconazole-resistant C. glabrata, AmB deoxycholate, 0.3-0.6 mg/kg daily for 1-7 days OR oral flucytosine, 25 mg/kg 4 times daily for 7-10 days is recommended. ( S/L )
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For C. krusei, AmB deoxycholate, 0.3-0.6 mg/kg daily, for 1-7 days is recommended. ( S/L )
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Removal of an indwelling bladder catheter, if feasible, is strongly recommended. ( S/L )
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AmB deoxycholate bladder irrigation, 50 mg/L sterile water daily for 5 days, may be useful for treatment of cystitis due to fluconazole-resistant species, such as C. glabrata and C. krusei. ( W/L )
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Symptomatic Ascending Candida Pyelonephritis

For fluconazole-susceptible organisms, oral fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks is recommended. ( S/L )
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For fluconazole-resistant C. glabrata, AmB deoxycholate, 0.3-0.6 mg/kg daily for 1-7 days with or without oral flucytosine, 25 mg/kg 4 times daily, is recommended. ( S/L )
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For fluconazole-resistant C. glabrata, monotherapy with oral flucytosine, 25 mg/kg 4 times daily for 2 weeks, could be considered. ( W/L )
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For C. krusei, AmB deoxycholate, 0.3-0.6 mg/kg daily, for 1-7 days is recommended. ( S/L )
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Elimination of urinary tract obstruction is strongly recommended. ( S/L )
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For patients who have nephrostomy tubes or stents in place, consider removal or replacement, if feasible. ( W/L )
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UTI Associated with Fungus Balls

Surgical intervention is strongly recommended in adults. ( S/L )
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Antifungal treatment as noted above for cystitis or pyelonephritis is recommended. ( S/L )
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Irrigation through nephrostomy tubes, if present, with AmB deoxycholate, 25-50 mg in 200-500 mL sterile water, is recommended. ( S/L )
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XV. Vulvovaginal Candidiasis

For the treatment of uncomplicated Candida vulvovaginitis, topical antifungal agents, with no one agent superior to another, are recommended. ( S/H )
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Alternatively, for the treatment of uncomplicated Candida vulvovaginitis, a single 150 mg oral dose of fluconazole is recommended. ( S/H )
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For severe acute Candida vulvovaginitis, fluconazole, 150 mg, given every 72 hours for a total of 2 or 3 doses, is recommended. ( S/H )
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For C. glabrata vulvovaginitis that is unresponsive to oral azoles, topical intravaginal boric acid, administered in a gelatin capsule, 600 mg daily, for 14 days is an alternative. ( S/L )
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Another alternative agent for C. glabrata infection is nystatin intravaginal suppositories, 100,000 units daily for 14 days. ( S/L )
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A third option for C. glabrata infection is topical 17% flucytosine cream alone or in combination with 3% AmB cream administered daily for 14 days. ( W/L )
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For recurring vulvovaginal candidiasis, 10-14 days of induction therapy with a topical agent or oral fluconazole, followed by fluconazole, 150 mg weekly for 6 months, is recommended. ( S/H )
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XVI. Oropharyngeal Candidiasis

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. ( S/H )
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Alternatives for mild disease include nystatin suspension, (100,000 U/mL) 4-6 mL 4 times daily, OR 1-2 nystatin pastilles, (200,000 U each) 4 times daily, for 7-14 days. ( S/M )
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For moderate to severe disease, oral fluconazole, 100-200 mg daily, for 7-14 days is recommended. ( S/H )
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For fluconazole-refractory disease, itraconazole solution, 200 mg once daily OR posaconazole suspension, 400 mg twice daily for 3 days then 400 mg daily, for ≤28 days is recommended. ( S/M )
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Alternatives for fluconazole-refractory disease include voriconazole, 200 mg twice daily, OR AmB deoxycholate oral suspension, 100 mg/mL 4 times daily. ( S/M )
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Intravenous echinocandin (caspofungin, 70 mg loading dose, then 50 mg daily, micafungin 100 mg daily, or anidulafungin, 200 mg loading dose, then 100 mg daily) OR intravenous AmB deoxycholate, 0.3 mg/kg daily, are other alternatives for refractory disease. ( W/M )
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Chronic suppressive therapy is usually unnecessary. If required for patients who have recurrent infection, fluconazole, 100 mg 3 times weekly, is recommended. ( S/H )
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For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections. ( S/H )
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For denture-related candidiasis, disinfection of the denture, in addition to antifungal therapy, is recommended. ( S/M )
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XVII. Esophageal Candidiasis

Systemic antifungal therapy is always required. A diagnostic trial of antifungal therapy is appropriate before performing an endoscopic examination. ( S/H )
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Oral fluconazole, 200-400 mg (3-6 mg/kg) daily, for 14-21 days is recommended. ( S/H )
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For patients who cannot tolerate oral therapy: Intravenous fluconazole, 400 mg (6 mg/kg) daily, OR an echinocandin (micafungin, 150 mg
daily, caspofungin, 70 mg loading dose, then 50 mg daily, or anidulafungin, 200 mg daily) is recommended. ( S/H )
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A less preferred alternative for those who cannot tolerate oral therapy is AmB deoxycholate, 0.3-0.7 mg/kg daily. ( S/M )
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Consider de-escalating to oral therapy with fluconazole 200-400 mg (3-6 mg/kg) daily once the patient is able to tolerate oral intake. ( S/M )
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For fluconazole-refractory disease, itraconazole solution, 200 mg daily, OR voriconazole, 200 mg (3 mg/kg) twice daily either IV or oral, for 14-21 days is recommended. ( S/H )
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Alternatives for fluconazole-refractory disease include an echinocandin (micafungin, 150 mg daily, caspofungin, 70 mg loading dose, then 50 mg daily, or anidulafungin, 200 mg daily) for 14-21 days, OR AmB deoxycholate, 0.3-0.7 mg/kg daily, for 21 days. ( S/H )
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Posaconazole suspension, 400 mg twice daily, or extended-release tablets, 300 mg once daily, could be considered for fluconazole-refractory disease. ( W/L )
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For patients who have recurrent esophagitis, chronic suppressive therapy with fluconazole, 100-200 mg 3 times weekly, is recommended. ( S/H )
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For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections. (S/H)
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Recommendation Grading

Overview

Title

Management of Candidiasis

Authoring Organization

Infectious Diseases Society of America

Publication Month/Year

December 16, 2015

Last Updated Month/Year

November 25, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

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. There are at least 15 distinct Candida species that cause human disease, but >90% of invasive disease is caused by the 5 most common pathogens, C. albicans, C. glabrata, C. tropicalis, C. parapsilosis, and C. krusei. Each of these organisms has unique virulence potential, antifungal susceptibility, and epidemiology, but taken as a whole, significant infections due to these organisms are generally referred to as invasive candidiasis. Mucosal Candida infections—especially those involving the oropharynx, esophagus, and vagina—are not considered to be classically invasive disease, but they are included in these guidelines. Since the last iteration of these guidelines in 2009, there have been new data pertaining to diagnosis, prevention, and treatment for proven or suspected invasive candidiasis, leading to significant modifications in our treatment recommendations.

Target Patient Population

Patients with candidiasis

PICO Questions

  1. What Is the Treatment for Candidemia in Nonneutropenic Patients?

  2. Should Central Venous Catheters Be Removed in Nonneutropenic Patients With Candidemia?

  3. What Is the Treatment for Candidemia in Neutropenic Patients?

  4. What Is the Treatment for Chronic Disseminated (Hepatosplenic) Candidiasis?

  5. What Is the Role of Empiric Treatment for Suspected Invasive Candidiasis in Nonneutropenic Patients in the Intensive Care Unit?

  6. Should Prophylaxis Be Used to Prevent Invasive Candidiasis in the Intensive Care Unit Setting?

  7. What Is the Treatment for Neonatal Candidiasis, Including Central Nervous System Infection?

  8. What Is the Treatment for Intra-abdominal Candidiasis?

  9. Does the Isolation of Candida Species From the Respiratory Tract Require Antifungal Therapy?

  10. What Is the Treatment for Candida Intravascular Infections, Including Endocarditis and Infections of Implantable Cardiac Devices?

  11. What Is the Treatment for Candida Osteoarticular Infections?

  12. What Is the Treatment for Candida Endophthalmitis?

  13. What Is the Treatment for Central Nervous System Candidiasis?

  14. What Is the Treatment for Urinary Tract Infections Due to Candida Species?

  15. What Is the Treatment for Vulvovaginal Candidiasis?

  16. What Is the Treatment for Oropharyngeal Candidiasis?

  17. What Is the Treatment for Esophageal Candidiasis?

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Ambulatory, Hospital

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D002175 - Candida, D002177 - Candidiasis

Keywords

fungal infection, candidiasis, azoles, Candida, invasive candidiasis, yeast infection, candidemia

Source Citation

Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, Reboli AC, Schuster MG, Vazquez JA, Walsh TJ, Zaoutis TE, Sobel JD. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Feb 15;62(4):e1-e50.

Methodology

Number of Source Documents
560
Literature Search Start Date
November 1, 2013
Literature Search End Date
January 1, 2014