Candidemia & Invasive Candidiasis Management (IDSA 2016)

Algorithm Steps

1. ▶

   Start

   Candidemia Diagnosed

   Blood culture positive for Candida species

   1. ●

      Action

      Initial Management

      Start antifungal immediately

      • Remove all central venous catheters
      • Repeat blood cultures daily until negative
      • Dilated ophthalmologic exam
      • Echo if prolonged candidemia or valve disease
      1. ●

         Action

         Empiric Antifungal Therapy

         Echinocandin first-line

         • Caspofungin 70mg load, then 50mg daily, OR
         • Micafungin 100mg daily, OR
         • Anidulafungin 200mg load, then 100mg daily
         • Fluconazole alternative if low resistance risk
         1. ◆

            Decision

            Candida Species Identification

            Critical for de-escalation

            1. ●

               Action

               C. albicans (Most Common)

               Usually fluconazole-susceptible

               • If stable and susceptible: Can de-escalate to Fluconazole 400mg daily
               • Continue echinocandin if critically ill
               1. ●

                  Action

                  Source Control

                  Essential for cure

                  • Remove all CVCs - do NOT attempt salvage
                  • Drain abscesses
                  • Evaluate for deep-seated infection: Eye, heart, kidney, liver, spleen
                  1. ●

                     Action

                     Ophthalmologic Exam

                     Within first week

                     • Chorioretinitis in 5-15%
                     • If positive: Intravitreal antifungal + systemic
                     • Longer duration of therapy needed
                     1. ●

                        Action

                        Duration of Therapy

                        14 days minimum from negative culture

                        • Uncomplicated: 14 days from first negative culture
                        • Endocarditis: 6 weeks after valve surgery
                        • Eye involvement: 4-6 weeks
                        • Deep-seated: Individualized
                        1. ✓

                           Outcome

                           Resolved

                           Negative cultures, completed therapy

                        2. ⚠

                           Warning

                           Complications

                           Endophthalmitis, endocarditis, metastatic

                  2. ●

                     Action

                     Echocardiogram

                     If risk factors

                     • Persistent candidemia >72h
                     • Prior valve disease, prosthetic valve
                     • IVDU
                     • TTE first; TEE if high suspicion
            2. ●

               Action

               C. glabrata

               Often fluconazole-resistant

               • Continue echinocandin
               • Await susceptibilities before considering azole
               • High-dose fluconazole 800mg if susceptible
            3. ●

               Action

               C. krusei

               Intrinsically fluconazole-resistant

               • Continue echinocandin
               • Voriconazole alternative if needed
            4. ⚠

               Warning

               C. auris

               Multi-drug resistant, infection control alert

               • Often resistant to fluconazole and echinocandins
               • Use echinocandin initially; await susceptibilities
               • Amphotericin B if echinocandin-resistant
               • Contact precautions, notify infection control