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Specific Organisms and Therapeutic Regimens
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Specific Organisms and Therapeutic Regimens

The Candida species produce a wide spectrum of diseases ranging from superficial to invasive illnesses.

Treatments used to manage Candida infections^[1]vary substantially and are based on the anatomic location of the infection, the patients’ underlying disease and immune status, the patients’ risk factors for infection, the specific species of Candida responsible for infection, and, in some cases, the susceptibility of the Candida species to specific antifungal drugs.^[2]

Urinary tract infections

Common organisms:

C albicans, C glabrata, C tropicalis

Asymptomatic cystitis:

Therapy not usually indicated, unless patients are at high risk
Patients undergoing urologic procedures: fluconazole 200-400 mg daily or amphotericin B deoxycholate (AmB-d) 0.3-0.6 mg/kg/day for several days before and after procedure

Symptomatic cystitis:

Fluconazole 200 mg daily for 14d or
Flucytosine 25 mg/kg QID for 7-10d or
AmB-d 0.3-0.6 mg/kg for 1-7d

Pyelonephritis:

Fluconazole 200-400 mg daily for 14d or
AmB-d 0.5-0.7 mg/kg with or without flucytosine 25 mg/kg QID or
Flucytosine 25 mg/kg QID for 14d alone

Vulvovaginal candidiasis

Treatment of vulvovaginal candidiasis includes the following:

Common organisms: C albicans, C glabrata, C tropicalis, C parapsilosis
Fluconazole 150 mg PO as a single dose for uncomplicated vaginitis or
Butoconazole 2% cream: 1 applicator per vagina q24h at bedtime for 3d or
Clotrimazole 100 mg: 2 tablets per vagina at bedtime for 3 nights or
Miconazole 200 mg vaginal suppository: 1 suppository at bedtime per vagina for 3d or
Ibrexafungerp 300 mg PO BID x 1 day^[5]

Recurrent vulvovaginal candidiasis^[3]:

Fluconazole 150 mg weekly for 6mo after initial control of the recurrent episode

Chronic disseminated candidiasis

Treatment of chronic disseminated candidiasis included the following:

Fluconazole 400 mg daily for stable patients or
Lipid formulation of amphotericin B (LFAmB): 3-5 mg/kg IV daily for severely ill patients or
AmB-d 0.5-0.7 mg/kg daily for severely ill patients
Therapy should continue until lesions have resolved (usually months)
Continue therapy through periods of immunosuppression; after patient is stable, switch to fluconazole

Alternative regimens:

Echinocandin therapy
Anidulafungin 200 mg loading dose, then 100 mg daily or
Caspofungin 70 mg loading dose, then 50 mg daily or
Micafungin 100 mg daily

CNS candidiasis

Treatment of CNS candidiasis includes the following:

Common organisms: C albicans, C glabrata, C tropicalis, C krusei, C parapsilosis^[4]
LFAmB 3-5 mg/kg IV daily with or without flucytosine 25 mg/kg QID for several weeks, followed by fluconazole 400-800 mg daily or
Fluconazole 400-800 mg daily for patients unable to tolerate LFAmB

Candida osteoarticular infection

Common organisms:

C albicans, C glabrata, C tropicalis, C krusei, C parapsilosis

Osteomyelitis:

Fluconazole 400 mg daily for at least 6-12mo or
LFAmB 3-5 mg/kg IV daily for at least 2wk, then fluconazole for 6-12mo or
Caspofungin 70 mg loading dose, then 50 mg daily or
Micafungin 100 mg daily or
Anidulafungin 200 mg loading dose, then 100 mg daily or
AmB-d 0.5-1 mg/kg daily for at least 2wk, then fluconazole for 6-12mo

Septic arthritis:

Fluconazole 400 mg daily for at least 6wk or
LFAmB 3-5 mg/kg IV daily for at least 2wk, followed by fluconazole 400 mg daily or
Caspofungin 70 mg loading dose, then 50 mg daily or
Micafungin 100 mg daily or
Anidulafungin 200 mg loading dose, then 100 mg daily or
AmB-d 0.5-1 mg/kg daily for at least 2wk, then fluconazole 400 mg for remainder of therapy
Duration of therapy: at least 6wk

Candida endophthalmitis

Treatment of Candida endophthalmitis includes the following:

Common organisms: C albicans, C glabrata, C tropicalis, C krusei, C parapsilosis
AmB-d 0.7-1 mg/kg plus flucytosine 25 mg/kg QID or
Fluconazole 400-800 mg daily (loading dose of 12 mg/kg, then 6–12 mg/kg daily) or
LFAmB 3-5 mg/kg daily or
Voriconazole 6 mg/kg BID for 2 doses, then 3-4 mg/kg BID or
Duration of therapy: at least 4-6wk
Surgical intervention for patients with severe endophthalmitis or vitreitis

Candida of the cardiovascular system

Common organisms:

C albicans, C glabrata, C tropicalis, C krusei, C parapsilosis

Endocarditis:

LFAmB 3-5 mg/kg daily IV with our without flucytosine 25 mg/kg QID or
AmB-d 0.6-1 mg/kg daily with or without flucytosine 25 mg/kg QID or
Caspofungin 50-150 mg daily or
Micafungin 100-150 mg daily or
Anidulafungin 100-200 mg daily
Valve replacement is highly recommended to improve outcome
If valve replacement is not performed, chronic suppression is recommended with fluconazole 400-800 mg daily
Lifelong suppressive therapy is recommended in prosthetic valve endocarditis if valve cannot be replaced

Pericarditis or myocarditis:

LFAmB 3-5 mg/kg daily or
Fluconazole 400-800 mg daily or
Caspofungin 50-150 mg daily or
Micafungin 100-150 mg daily or
Anidulafungin 100-200 mg daily
After patient is stable, step-down therapy to fluconazole 400-800 mg daily can be initiated
Duration of therapy: often for several months

Suppurative thrombophlebitis:

LFAmB 3-5mg/kg IV daily or
Fluconazole 400-800 mg daily or
Caspofungin 50-150 mg daily or
Micafungin 100-150 mg daily or
Anidulafungin 100-200 mg daily
After patient is stable, step-down therapy to fluconazole 400-800 mg daily can be initiated
Treat for at least 2wk after candidemia has cleared
Surgical incision and drainage or resection of infected vessel may be necessary

Nongenital mucocutaneous candidiasis

Common organisms:

C albicans, C glabrata, C tropicalis, C dubliniensis, C parapsilosis

Oropharyngeal:

Uncomplicated disease:

7-14d of therapy for uncomplicated infections

Moderate to severe disease:

Fluconazole is recommended

Mild disease:

Topical therapy with clotrimazole or nystatin is usually recommended

Refractory disease (use itraconazole, voriconazole, posaconazole, or amphotericin B [AmB] suspension):

Clotrimazole troches 10 mg 5 times daily or
Nystatin suspension or pastilles QID or
Fluconazole 100-200 mg PO daily or
Itraconazole solution 200 mg PO daily or
Miconazole buccal tablets 50 mg daily or
Posaconazole 400 mg PO daily or
Voriconazole 200 mg PO BID or
AmB-d 0.3 mg/kg daily

Esophageal:

Fluconazole 200-400 mg PO daily or
AmB-d 0.3-0.7 mg/kg daily or
Caspofungin 50 mg daily or
Micafungin 150 mg daily or
Anidulafungin 200 mg daily or
Voriconazole 200 mg PO BID or
Posaconazole 400 mg PO BID or
Itraconazole oral solution 200 mg PO daily
Duration of therapy: 14-21d

Candidemia

Common organisms:

C albicans, C glabrata, C tropicalis, C krusei, C parapsilosis, C auris

Nonneutropenia patients:

Drug of choice should be an echinocandin:
- Caspofungin 70 mg loading dose, then 50 mg daily or
- Micafungin 100 mg daily or
- Anidulafungin 200 mg loading dose, then 100 mg daily or
Fluconazole 800 mg loading dose, then 400 mg daily or
LFAmB 3-5mg/kg IV daily or
AmB-d 0.5-1 mg/kg daily or
Voriconazole 400 mg BID for 2 doses, then 200 mg BID
Treatment for 14d after first negative blood culture result and resolution of signs and symptoms
It is important to note the increase in invasive candidiasis infections due to C auris over the past few years. It is significant becasue of its intrinsic multidrug resistant characteristics. If C auris is identified, initial therapy should be initiated with an echinocandin and in vitro susceptibilities should be done. (Forsberg et al, Biagi et al.)