Candidiasis in Emergency Medicine Guidelines

Updated: Oct 05, 2021
  • Author: Ivan L Yue, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Guidelines

Infectious Diseases Society of America Guidelines for the Treatment of Candida Infections

Guidelines on the treatment of Candida infections by the Infectious Diseases Society of America are as follows [33] :

  • The IDSA recommends an echinocandin as first-line treatment for candidemia (caspofungin: loading dose 70 mg, then 50 mg daily; micafungin: 100 mg daily; anidulafungin: loading dose 200 mg, then 100 mg daily), rather than fluconazole, as echinocandins kill, rather than inhibit, these pathogens.
  • 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.
  • In neutropenic patients, lipid formulation amphotericin B, 3-5 mg/kg daily, is an effective but less attractive alternative because of the potential for toxicity.
  • Fluconazole could be used in high-risk patients in adult ICUs with a high rate (>5%) of invasive candidiasis.
  • Daily bathing of ICU patients with chlorhexidine, which has been shown to decrease the incidence of bloodstream infections including candidemia, could be considered.
  • The updated guidelines also advocate consultation with infectious disease specialists for the early identification of different Candida strains, optimal antifungal treatment, and better patient outcomes.
  • The guidelines advocate testing for azole susceptibility in clinically relevant Candida isolates. Testing for echinocandin susceptibility should be considered in patients who have undergone prior treatment with an echinocandin and in those with C glabrata or C parapsilosis infection.
  • Candidiasis should be considered in patients who deteriorate with no obvious cause, have unexplained fever, have an elevated white blood cell count, have recently undergone abdominal surgery, or have a central venous catheter.
  • Remove a catheter as early as possible in patients with candidemia if the catheter is the presumed source and can be safely removed. Other intravascular devices should also be removed.
  • For neonatal candidiasis, amphotericin B deoxycholate 1 mg/kg daily is recommended for neonates with disseminated candidiasis.
  • Lumbar puncture and dilated retinal examination are recommended in neonates with serum or urine cultures that are positive for Candida species .
  • Empiric antifungal therapy should be considered in patients with clinical evidence of intra-abdominal infection and significant risk factors for candidiasis, including recent abdominal surgery, anastomotic leaks, or necrotizing pancreatitis.
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016

Guidelines on the consideration and treatment of candidiasis as a cause of sepsis by the 2016 Surviving Sepsis Campaign International Guidelines are as follows [25]

  • Invasive candidiasis should be considered in selected patients. For example, neutropenic patients are at risk for an especially wide range of potential pathogens, including Candida species.
  • Risk factors for invasive Candida infections include immunocompromised status (neutropenia, chemotherapy, transplant, diabetes mellitus, chronic liver failure, chronic renal failure), prolonged invasive vascular devices (hemodialysis catheters, central venous catheters), total parenteral nutrition, necrotizing pancreatitis, recent major surgery (particularly abdominal), prolonged administration of broad-spectrum antibiotics, prolonged hospital/ICU admission, recent fungal infection, and multisite colonization. [34, 35]
  • If the risk of Candida sepsis is sufficient to justify empiric antifungal therapy, the selection of the specific agent should be tailored to the severity of illness, the local pattern of the most prevalent Candida species, and any recent exposure to antifungal drugs.
  • Empiric use of an echinocandin (anidulafungin, micafungin, or caspofungin) is preferred in most patients with severe illness, especially in those patients with septic shock, who have recently been treated with other antifungal agents, or if Candida glabrata or Candida krusei infection is suspected from earlier culture data. [33, 36]
  • Triazoles are acceptable in hemodynamically stable, less ill patients who have not had previous triazole exposure and are not known to be colonized with azole-resistant species.
  • Liposomal formulations of amphotericin B are a reasonable alternative to echinocandins in patients with echinocandin intolerance or toxicity. [33, 36]
  • Knowledge of local resistance patterns to antifungal agents should guide drug selection until fungal susceptibility test results, if available, are received.
  • Rapid diagnostic testing using β-D-glucan or rapid polymerase chain reaction assays to minimize inappropriate anti-Candida therapy may have an evolving supportive role. However, the negative predictive value of such tests is not high enough to justify dependence on these tests for primary decision-making.
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