Candidemia / Invasive Candidiasis

Bloodstream

Patient + scenario modifiers

Patient

Clinical scenario / source

Annotations only — chart still shows the full chemistry of each drug.

1. Clinical Syndrome

Bloodstream infection with Candida species, with or without identified focus. Risk of metastatic seeding (eyes, heart valves, kidneys, bones, vertebra). All patients with candidemia require workup for endorgan involvement: ophthalmology exam, echocardiogram if persistent.

2. Pathogens

Consider the patient: Central venous catheter (esp. TPN — C. parapsilosis), prior fluconazole exposure (selects for non-albicans / glabrata / krusei), neutropenia, broad-spectrum antibiotics, abdominal surgery, hemodialysis, ICU stay, advanced age.

Consider the case: Speciation drives empirics — fluconazole-S albicans behaves very differently from glabrata or auris. Send T2 Candida PCR (rapid, before culture growth) and serum 1,3-β-D-glucan. ALL candidemia mandates ophtho exam (chorioretinitis 9–15%) and TEE if persistent ≥72 h or prosthetic material.

Common

- Candida albicans
  Most common species; usually fluconazole-susceptible.
- Candida glabrata (Nakaseomyces glabratus)
  Higher MIC; intrinsic dose-dependent fluconazole susceptibility; echinocandin first-line.
- Candida parapsilosis
  Line / TPN association; biofilm; fluconazole preferred over echinocandin.

Less common

- Candida krusei (Pichia kudriavzevii)
  Intrinsic fluconazole resistance — never empiric fluconazole.
- Candida auris
  Multi/pan-resistant outbreaks — call ID + public health.

3. Empiric Therapy

Tier	First choice	Alternatives	Duration	Comments
Admitted to ward	100 mg · q24h · IV · 14 days from first negative blood culture First-line for stable candidemia of any species pending speciation.	70 mg load → 50 mg · q24h · IV · 14 days Alternative echinocandin. 800 mg load → 400 mg (6 mg/kg) · q24h · IV/PO · 14 days ONLY if confirmed C. albicans / parapsilosis fluc-S, clinically improving, no prior fluconazole exposure.	14 days from first NEGATIVE blood culture (uncomplicated candidemia)	Stable hemodynamics. Empiric echinocandin until species + susceptibility back. Step down to fluconazole only when albicans/parapsilosis confirmed and clinically improving.
Acute / severe	100 mg · q24h · IV Echinocandin core — broadest empiric coverage including glabrata / krusei. 3–5 mg/kg · q24h · IV Add for septic shock, suspected CNS / endovascular / endophthalmitis, or echinocandin-resistant species.	3–5 mg/kg · q24h · IV Monotherapy if echinocandin contraindicated or pan-resistant species (e.g., echino-R C. auris).	≥14 days from first negative blood culture; longer for endocarditis (4–6 weeks min, often switch to oral azole step-down) or osteomyelitis (6–12 months)	Septic shock, suspected endocarditis or endophthalmitis, hematologic malignancy with neutropenia, or echinocandin-resistant species suspected. Add liposomal amphotericin B to echinocandin or replace.
Chronic outpatient	400 mg (6 mg/kg) · PO daily · PO Step-down ONLY after speciation (albicans / parapsilosis fluc-S confirmed) and clinical improvement on echinocandin.	200 mg · PO BID · PO Step-down for fluconazole-resistant non-albicans (e.g., susceptible C. krusei). 300 mg · PO daily · PO Salvage / pan-azole-active species.	—	Oral step-down regimen. Continue to complete the 14-day course after first negative culture (or longer for complicated candidemia). Susceptibility-driven choice.

4. Directed Therapy

Source control is essential:

Remove all central venous catheters when feasible (especially with C. parapsilosis — line-associated). If line cannot be removed, longer treatment duration and antifungal lock therapy.
Ophtho exam within 1 week — chorioretinitis / endophthalmitis in 9–15%. Treatment changes if endophthalmitis (intravitreal voriconazole or amphotericin + systemic).
Echo (TEE) if persistent ≥72 h or prosthetic material — endocarditis requires 4–6 weeks min, often surgical valve replacement.
Repeat blood cultures daily until clearance.

Species-directed step-down:

C. albicans, parapsilosis (fluc-S) → fluconazole 400 mg PO daily
C. glabrata (DDS / S-DD) → echinocandin or higher-dose fluconazole 800 mg if susceptible
C. krusei → voriconazole or echinocandin (NEVER fluconazole)
C. auris → susceptibility-driven; ID + public health

Treat 14 days from first negative blood culture — count starts from the first negative, not from initiation.

5. Monitoring

Daily blood cultures until clearance. Daily clinical exam for new metastatic signs (back pain → vertebral osteomyelitis; visual symptoms → endophthalmitis; new murmur → endocarditis).

Drug toxicity:

Echinocandin: LFTs (transaminitis); rare infusion reactions
Liposomal ampho B: BMP daily (nephrotoxicity, hypokalemia, hypomagnesemia); pre-medicate if rigors
Fluconazole: LFTs; QTc; CYP interactions

Pearls

Every candidemia patient needs:

Ophtho exam within 1 week (chorioretinitis 9–15%)
Central line removal when feasible
TEE if persistent ≥72 h or prosthetic material
14 days from first NEGATIVE culture (not from start)

Echinocandin first-line, EXCEPT C. parapsilosis (intrinsically elevated echinocandin MICs — IDSA suggests continuing if doing well, but fluconazole preferred when stable).

Don't reflexively step down to fluconazole — wait for species + susceptibility + clinical improvement. C. glabrata and C. krusei are the trap species.

C. auris: report to public health; contact precautions; consider chlorhexidine bathing; pan-resistant strains have been reported.