New Guideline Calls for Aggressive Treatment of Candidiasis

Diana Swift

December 23, 2015

Updated guidelines from the Infectious Diseases Society of America (IDSA) for managing Candida infections recommend first-line treatment for candidemia with an echinocandin such as caspofungin, rather than fluconazole, as echinocandins kill, rather than inhibit, these pathogens.

The new guidelines, which replace those from 2009, were published online December 16 in Clinical Infectious Diseases.

The updated guideline also advocates consultation with infectious disease specialists for the early identification of different Candida strains, optimal antifungal treatment, and better patient outcomes. It covers numerous topics from candidemia, neonatal candidiasis, and intravascular infections to intensive care unit prophylaxis, central nervous system involvement, and mucosal infections.

"Since the last iteration of these guidelines in 2009, there have been new data pertaining to diagnosis, prevention, and treatment for proven or suspected invasive candidiasis, leading to significant modifications in our treatment recommendations," writes a panel led by Peter Pappas, MD, a professor of medicine in the Division of Infectious Diseases at the University of Alabama at Birmingham.

Other Recommendations

Addressing concerns about the growing prevalence of antifungal resistance, the guideline also advocates testing for azole susceptibility in clinically relevant Candida isolates. "Testing for echinocandin susceptibility should be considered in patients who have had prior treatment with an echinocandin and among those who have infection with C. glabrata or C. parapsilosis," the guideline adds.

The update also recommends a step-down approach, initiating treatment with an intravenous antifungal such as an echinocandin and then switching to an oral treatment, such as fluconazole.

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, according to the new guidelines. They also recommend the removal of a catheter as early as possible in candidemia if the catheter is the presumed source and can be safely removed. Other intravascular devices should also be removed.

Because a rapid specific diagnostic test remains lacking, and diagnosis and treatment across strains remain challenging, consultation with an infectious disease specialist is recommended.

Early action is key. "Time to appropriate therapy in candidemia appears to have a significant impact on the outcome of patients with this infection," the guideline states. "A safe and effective prophylactic strategy to prevent candidemia among high-risk patients could be of great benefit." In particular, in intensive care units with rates of invasive candidiasis elevated beyond the expected rate of less than 5%, antifungal prophylaxis may be warranted in selected high-risk patients.

Invasive candidiasis is one of the most serious nosocomial infections. "In fact, patients who get candidemia are more likely to die than those whose bloodstream infections are caused by bacteria," Dr Pappas said in an IDSA statement. Also according to the statement, some studies have reported a mortality rate as high as 47% in affected patients.

The guideline notes that more than 90% of potentially life-threatening deep-tissue disease is caused by five of 15 fungal pathogens: C. albicans, C. glabrata, C. tropicalis, C. parapsilosis, and C. krusei.

The new recommendations have been endorsed by the Academy of Pediatrics, the Pediatric Infectious Diseases Society, and the Mycoses Study Group.

Support for this guideline was provided by IDSA. A majority of the authors disclosed relationships with industry outside the submitted work, including research grants, consulting or speaking fees, and royalties or patents.

Clin Infect Dis. Published online December 16, 2015. Full text

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