Candidiasis

Candida Infections of the Cardiovascular System Condition Primary Alternative Comments Endocarditis LFAmB 3-5 mg/kg +/- 5-FC 25 mg/kg qid or AmB-d 0.6-1 mg/kg daily +/- 5-FC 25 mg/kg qid or an echinocandin* (B-III) Step-down therapy to fluconazole 400-800 mg (6-12 mg/kg) daily for susceptible organism in stable patient with negative blood cultures (B-III) Valve replacement strongly recommended. If unable to remove valve, chronic suppression fluconazole 400-800 mg (6-12 mg/kg) daily. Life-long suppressive therapy for prosthetic valve endocarditis if valve cannot be replaced. Pericarditis, myocarditis LFAmB 3-5 mg/kg daily, or fluconazole 400-800 mg (6-12 mg/kg) daily, or an echinocandin* (B-III) After stable, stepdown to fluconazole 400-800 mg (6-12 mg/kg) daily (B-III) Therapy for several months but little data. Pericardial window or pericardiectomy recommended. Suppurative LFAmB 3-5 mg/kg daily, thrombo-phlebitis or fluconazole 400-800 mg (6-12 mg/kg) daily, or an echinocandin* (B-III) After stable, stepdown to fluconazole 400-800 mg (6-12 mg/kg) daily (B-III) Catheter removal essential Surgical incision and drainage or resection of vein if feasible. Treat for at least 2 wk after candidemia has cleared. Infected pacemakers, ICD, VAD Step-down therapy to fluconazole 400-800 mg (6-12 mg/kg) daily for susceptible organism in stable patient with negative blood cultures (B-III) Removal of pacemakers and ICD. Treat for 4-6 weeks after device removed. For VAD that cannot be removed, chronic suppressive therapy with fluconazole is recommended. LFAmB 3-5 mg/kg +/- 5-FC 25 mg/kg qid or AmB-d 0.6-1 mg/kg daily +/- 5-FC 25 mg/kg qid or an echinocandin* (B-III) * For patients with endocarditis and other cardiovascular infections, higher daily doses of an echinocandin may be appropriate, eg, caspofungin 50-150 mg/d, micafungin 100-150 mg/d, anidulafungin 100-200 mg/d. Candida Osteoarticular Infections Condition Primary Alternative Comments Osteomyelitis Fluconazole 400 mg (6 mg/kg)/d for 6-12 mo or LFAmB 3-5 mg/kg daily for several wk, then fluconazole for 6-12 mo (B-III) An echinocandin* or AmB-d 0.5-1 mg/kg daily for several wks, then fluconazole for 6-12 mo (B-III) Duration of therapy usually is prolonged (6-12 months). Surgical debridement is frequently necessary. Septic arthritis Fluconazole 400 mg (6 mg/kg)/d for at least 6 wk or LFAmB 3-5 mg/kg daily for several wks, then fluconazole to completion (B-III) An echinocandin** or AmB-d 0.5-1 mg/kg daily for several wks, then fluconazole to completion (B-III) Duration of therapy usually for at least 6 wk, but few data are available. Surgical debridement recommended for all cases. Prosthetic joint removal recommended. **Echinocandin dosing in adults is anidulafungin, 200 mg loading then 100 mg/d, caspofungin, 70 mg loading then 50 mg/d, and micafungin, 100 mg/d.

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