Candidaemia in an adult
Candida species grown from a blood culture. Adult pathway. Neonates and children need paediatric dosing and a paediatric pathway.
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Infectious DiseaseManagement
Candidemia & Invasive Candidiasis Management (IDSA 2016)
Candidemia & Invasive Candidiasis Management (IDSA 2016): Candidaemia in an adult → Pregnancy, neutropenia or recent antifungal use change the plan → St...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Warning Pregnancy, neutropenia or recent antifungal use change the plan
Adults only: neonates and children need paediatric doses and advice. Check these before you choose the drug.
- Pregnancy: use liposomal amphotericin B. Avoid fluconazole and other azoles (birth defects, mainly first trimester); voriconazole is contraindicated. Echinocandins: few data, use only with ID and obstetric advice.
- Neutropenia: echinocandin first (liposomal amphotericin B is the alternative). The gut is often the source, so decide CVC removal case by case. Do the eye exam after neutrophil recovery.
- Recent azole or echinocandin, or known C. auris: resistance is likely. Do not rely on that drug class until susceptibility is known.
03Action Start an echinocandin now (adult doses)
First choice for all adults, and always if critically ill or neutropenic. Not in pregnancy (see above).
- Caspofungin 70 mg IV load, then 50 mg IV daily (moderate hepatic impairment: 35 mg daily after the load; on rifampicin: 70 mg daily; consider 70 mg daily with other enzyme inducers)
- OR micafungin 100 mg IV daily
- OR anidulafungin 200 mg IV load, then 100 mg IV daily
- Fluconazole 800 mg load, then 400 mg (6 mg/kg, max 800 mg) daily, IV or oral: only if not critically ill, no recent azole and fluconazole resistance unlikely. CrCl 50 mL/min or less: halve the daily dose after the load
- Liposomal amphotericin B 3 to 5 mg/kg IV daily: if pregnant, echinocandin intolerance, or echinocandin resistance or failure
04Action Remove the central line and control the source
Remove the CVC as early as possible (aim within 48 to 72 h) when it can be removed safely. Neutropenia: decide case by case.
- Drain abscesses and remove other infected devices
- Pacemaker or ICD infection: remove the whole device
05Action Blood cultures, susceptibility testing and ID consult
Repeat blood cultures daily until they are negative, to date clearance.
- Test azole susceptibility on every blood isolate
- Test echinocandin susceptibility after prior echinocandin, and for C. glabrata or C. parapsilosis
- Infectious diseases or clinical microbiology consultation for every patient
06Decision Species and susceptibility result
Adjust the drug to the species and the susceptibility result.
- C. albicans or other fluconazole-susceptible
07Action Fluconazole-susceptible (e.g. C. albicans): step down when criteria are met
After 5 to 7 days of echinocandin, if ALL apply: clinically stable, isolate fluconazole-susceptible, repeat blood cultures negative, source controlled. Not in pregnancy.
- Fluconazole 400 mg (6 mg/kg, max 800 mg) daily, oral or IV (CrCl 50 mL/min or less: halve the dose; haemodialysis: full dose after each session)
- Neutropenia: step down only with ID advice
- Fluconazole interacts with warfarin, some statins and QT-prolonging drugs: review the drug chart
- Not stable or cultures still positive: continue the echinocandin
- C. parapsilosis
08Action C. parapsilosis: fluconazole if susceptible
Echinocandin MICs are higher for this species. Fluconazole-resistant strains are increasing: wait for susceptibility.
- Susceptible: fluconazole 400 mg daily (step-down criteria as for C. albicans)
- Improving on an echinocandin with negative cultures: continuing it is acceptable
- Very often linked to a CVC: make sure the line is out
- C. glabrata
09Action C. glabrata (Nakaseomyces glabratus): continue the echinocandin
Often fluconazole-resistant. Test echinocandin susceptibility.
- Step down only if fluconazole susceptible-dose dependent (SDD): fluconazole 800 mg daily (CrCl 50 mL/min or less: 400 mg daily). Or, if voriconazole-susceptible: voriconazole 200 to 300 mg twice daily (TDM; many drug interactions; not in pregnancy)
- Echinocandin-resistant, or azole- and echinocandin-resistant: liposomal amphotericin B 3 to 5 mg/kg IV daily; ID advice
- C. krusei
10Action C. krusei (Pichia kudriavzevii): continue the echinocandin
Intrinsically fluconazole-resistant: do not use fluconazole.
- Alternative: liposomal amphotericin B 3 to 5 mg/kg IV daily
- Oral step-down in selected cases: voriconazole if susceptible (ID advice; therapeutic drug monitoring; many drug interactions; not in pregnancy)
- C. auris
11Warning C. auris (Candidozyma auris): isolate the patient and notify infection control
Often multidrug-resistant and spreads between patients.
- Contact precautions in a single room; notify infection prevention and control and report as local public health rules require
- Echinocandin first. Test susceptibility to all drug classes; do not use fluconazole unless proven susceptible
- Echinocandin-resistant, or no improvement after 5 days: liposomal amphotericin B 5 mg/kg IV daily; ID advice
- Other or pending
12Action Other species, or result not yet back: continue the echinocandin
Do not step down until species and susceptibility are known.
- Change only to a drug the isolate is susceptible to
- Rare or resistant species: ID or clinical microbiology advice
13Action All species: dilated eye exam by an ophthalmologist in the first week
All non-neutropenic patients. Neutropenia: examine in the first week after neutrophil recovery.
- Chorioretinitis or endophthalmitis: ophthalmologist and ID physician plan treatment together
- Echinocandins reach the eye poorly: use fluconazole or voriconazole if susceptible; liposomal amphotericin B if resistant
- Macular involvement or vitritis: add intravitreal amphotericin B deoxycholate 5 to 10 microgram/0.1 mL or voriconazole 100 microgram/0.1 mL; vitritis: consider vitrectomy
- Eye involvement: treat at least 4 to 6 weeks, until repeat eye exams show resolution
14Action All species: echocardiogram if endocarditis is possible
Persistent candidaemia, valve disease or prosthetic valve, cardiac device, new murmur or embolic signs.
- TTE first; TOE if suspicion remains
- Candida endocarditis: cardiac surgery referral for valve replacement
- Endocarditis drugs: liposomal amphotericin B 3 to 5 mg/kg IV daily, OR high-dose echinocandin (caspofungin 150 mg, micafungin 150 mg or anidulafungin 200 mg IV daily)
- Stable, cultures cleared and isolate susceptible: step down to fluconazole 400 to 800 mg daily
- Treat at least 6 weeks after valve surgery; longer with abscess. No surgery possible: long-term fluconazole suppression (400 to 800 mg daily) if susceptible
15Decision Blood cultures negative and patient improving by day 5?
Repeat cultures daily until clearance is documented.
- If Yes
16Action Uncomplicated candidaemia: treat 14 days after the first negative blood culture
Without metastatic spread: 2 weeks after documented clearance and resolution of symptoms. Neutropenia: also until neutrophil recovery.
- Eye involvement: at least 4 to 6 weeks
- Endocarditis: at least 6 weeks after valve surgery
- Hepatosplenic (chronic disseminated) candidiasis: until lesions resolve on imaging, usually months
- Pacemaker or ICD infection: 4 weeks after device removal if only the pocket is infected; at least 6 weeks after lead removal if leads are infected
17Outcome Treatment complete
Cultures cleared, course finished and symptoms resolved.
If No18Action Persistent candidaemia or no improvement: search and escalate
Blood cultures still positive at day 5 or later, or clinical deterioration.
- Search again for an uncontrolled source: retained line, septic thrombophlebitis, abscess, endocarditis, eye
- Remove every remaining line or device if you can
- Test echinocandin susceptibility; for resistance or failure change class (liposomal amphotericin B 3 to 5 mg/kg IV daily)
- ID consult now if not done
- Path rejoins step 16Shared downstream outcome
Guideline Source
IDSA Clinical Practice Guideline for the Management of Candidiasis: 2016 Update (Pappas et al), checked against the ECMM/ISHAM/ASM Global Candidiasis Guideline 2025
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adult doses only. Neonates, children and pregnancy need specialist advice; liposomal amphotericin B is the drug of choice in pregnancy.
- Resistance varies by region and hospital (C. auris, fluconazole-resistant C. parapsilosis, C. glabrata): follow local susceptibility data and ID advice.
- The 2025 ECMM/ISHAM/ASM global guideline advises eye exams for selected patients; IDSA 2016 advises a dilated eye exam for all non-neutropenic patients, which this pathway follows.
- Does not cover CNS, intra-abdominal, urinary or oesophageal candidiasis, or antifungal prophylaxis.
- Rezafungin (weekly echinocandin) is an option in the 2025 global guideline and is not listed here.
Contraindicated Populations
Neonates and children (paediatric doses and neonatal disease differ)Pregnancy (use liposomal amphotericin B; azoles and voriconazole harmful; echinocandins need specialist advice)CNS or ocular-only candidiasis (echinocandins penetrate poorly)
Applicable Regions
USEUAUGlobal
AU: Australasian consensus: Keighley C et al, invasive candidiasis in haematology, oncology and intensive care, Intern Med J 2021;51 Suppl 7:89-117. Follow local antifungal stewardship policy. C. auris: notify infection prevention and control and follow state public health reporting rules.
Global: ECMM/ISHAM/ASM Global Candidiasis Guideline 2025 (Lancet Infect Dis 2025;25:e280-e293): echinocandins first line; step down to an oral azole after 5 or more days when stable, cleared, non-neutropenic, source controlled and susceptible.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Candidemia & Invasive Candidiasis Management (IDSA 2016)?
The Candidemia & Invasive Candidiasis Management (IDSA 2016) is a management clinical algorithm for Infectious Disease. It provides a structured decision tree to guide clinical decision-making, based on IDSA Clinical Practice Guideline for the Management of Candidiasis: 2016 Update (Pappas et al), checked against the ECMM/ISHAM/ASM Global Candidiasis Guideline 2025.
What guideline is the Candidemia & Invasive Candidiasis Management (IDSA 2016) based on?
This algorithm is based on IDSA Clinical Practice Guideline for the Management of Candidiasis: 2016 Update (Pappas et al), checked against the ECMM/ISHAM/ASM Global Candidiasis Guideline 2025 (DOI: 10.1093/cid/civ933).
What are the limitations of the Candidemia & Invasive Candidiasis Management (IDSA 2016)?
Known limitations include: Adult doses only. Neonates, children and pregnancy need specialist advice; liposomal amphotericin B is the drug of choice in pregnancy.; Resistance varies by region and hospital (C. auris, fluconazole-resistant C. parapsilosis, C. glabrata): follow local susceptibility data and ID advice.; The 2025 ECMM/ISHAM/ASM global guideline advises eye exams for selected patients; IDSA 2016 advises a dilated eye exam for all non-neutropenic patients, which this pathway follows.; Does not cover CNS, intra-abdominal, urinary or oesophageal candidiasis, or antifungal prophylaxis.; Rezafungin (weekly echinocandin) is an option in the 2025 global guideline and is not listed here.. Individual patient factors may require deviation from these recommendations.
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