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Candida laryngitis
Candida peritonitis
Candida pneumonia
Candiduria in critically ill

Candidaemia & acute disseminated candidiasis

Epidemiology

  • fungi 4th most common cause of nosocomial bloodstream infection in USA
  • high proportion of patients with fungaemia are critically ill

Treatment

Proven candidaemia or acute disseminated candidiasis

  • remove all central intravenous catheters if possible
    • greater benefit in non-neutropaenic patients
    • particularly important for C. parapsilosis infection - more frequently associated with CVC infection
  • drug treatment options (table):
  • duration of treatment
    • at least 2 weeks after last positive blood culture and resolution of clinical features of infection
  • treatment failure
    • breakthrough or persistence of candidaemia despite on-going antifungal therapy suggests:
      • infected intravascular device
      • significant immunosuppression
      • drug resistance
    • management
      • start different class of anti-fungal immediately
      • identify species of Candida and consider susceptibility testing
      • remove infected intravascular device
      • ameliorate immunosuppression if possible
  • ophthalmological examination for candida enophthalmitis
    • non-neutropaenic patients: at least once, preferably at a time when candidaemia appears controlled and subsequent spread to eye is unlikely
    • neutropaenic patients: after recovery of neutrophil count

Clinical setting Drug of choice Comments
Non-neutropaenic adults Amphotericin B or fluconazole or caspofungin Consider fluconazole in clinically stable patients who have not previously received azoles
Neutropaenic adult Amphotericin B (standard or lipid preparation) or caspofungin Fluconazole considered second line therapy. Resistance is often a significant problem due to prior exposure to azoles
C.albicans, C. tropicalis or C. parapsilosis Amphotericin B or fluconazole or caspofungin  
C. glabrata Caspofungin Reduced susceptibility to azoles and amphotericin. Amphotericin B (usual dose) and fluconazole 12 mg/kg may be suitable, particularly in less critically ill patients
C. krusei Amphotericin B (1mg/kg/day) or voriaconazole  
C.lusitaniae Fluconazole (6 mg/kg/day) Voriaconazole and caspofungin expected to be active against this species

Suspected disseminated candidiasis in non-neutropaenic patients

If therapy is given it should be limited to patients with:

  • Candida colonization (preferably multiple sites). NB absence of colonization indicates lower risk of invasive candidiasis and warrants delaying empirical therapy
  • multiple other risk factors, such as:
    • prolonged antibacterial use
    • central venous catheter
    • parenteral nutrition
    • surgery (especially surgery which transects bowel wall)
    • prolonged ICU stay
  • AND absence of any other uncorrected causes of fever

Empirical therapy for neutropaenic patients with prolonged fever despite anti-bacterials

  • ~20 % of neutropaenic patients with persistent fever despite broad-spectrum antibiotics develop an overt invasive fungal infection
  • Antifungals appropriate for neutropaenic patients with:
    • persistent unexplained fever
    • 4-7 days of appropriate antibacterial therapy
  • Regimes:
    • amphotericin 0.5-0.7 mg/kg/day. Liposomal amphotericin (~3 mg/kg/day) equally effective but less toxic and associated with lower incidence of breakthrough fungal infections
    • voriaconazole. Restrict use to allogenic bone marrow transplant recipients and patients with relapsed leukaemia
    • fluconazole (400 mg/day) can be considered in patients who:
      • are at low risk of invasive aspergillosis
      • has no clinical features suggesting aspergilosis
      • is at low risk of azole-resistant Candida
      • has not received prophylactic azole

Candida endocarditis

  • high morbidity and mortality
  • surgical replacement of infected valve
  • amphotericin B ± flucytosine at maximum tolerated doses for at least 6 weeks after surgery

Candida meningitis

  • high morbidity and mortality
  • amphotericin B 0.7-1 mg/kg/day plus flucystosine 25 mg/kg 6 hourly
    • adjust flucytosine dose to produce levels of 40-60 mcg/ml
    • continue treatment for minimum of 4 weeks after resolution of all clinical signs of infection
  • remove prosthetic devices

Further reading

Pappas PG. Guidelines for treatment of candidiasis. Clin Infect Dis 2004; 38:161-89

©Charles Gomersall, August, 2008 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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