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Management
I. Candidemia in Non-Neutropenic Patients
Î 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).
Î 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).
Î 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).
Î 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).
Î 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).
Î 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).
Î 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).
Î Among patients with suspected azole and echinocandin-resistant
Candida infections, lipid formulation AmB (3-5 mg/kg/d) is
recommended (S/L).
Î 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). Voriconazole
is recommended as step-down oral therapy for selected cases of
candidemia due to C. krusei (S/L).
Î 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).
