Invasive
Candida infections represent a diagnostic and therapeutic challenge for clinicians particularly in the intensive care unit (ICU). Despite substantial advances in
antifungal agents and treatment strategies,
invasive candidiasis remains associated with a high mortality. Recent guideline recommendations on the management of
invasive candidiasis by the European Society of Clinical Microbiology and
Infectious Diseases (ESCMID) from 2012, the German Speaking Mycological Society and the Paul Ehrlich Society for
Chemotherapy (DMykG/PEG) from 2011 and the
Infectious Diseases Society of America (IDSA) from 2009 provide valuable guidance for diagnostic procedures and treatment of these
infections but need to be interpreted in the light of the individual situation of the patient and the local epidemiology of fungal pathogens. The following recommendations for management of
candidemia are common to all three guidelines. Any positive blood culture for Candida indicates disseminated
infection or deep organ
infection and requires antifungal
therapy. Treatment should be initiated as soon as possible. Removal or changing of
central venous catheters or other foreign material in the bloodstream is recommended whenever possible. Ophthalmological examination for exclusion of
endophthalmitis and follow-up blood cultures during
therapy are also recommended.
Duration of therapy should be 14 days after clearance of blood cultures and resolution of symptoms. Consideration of surgical options and a prolonged antifungal treatment (weeks to months) are required when there is organ involvement. During the last decade several new
antifungal agents were introduced into clinical practice. These innovative drugs showed convincing efficacy and favorable safety in randomized clinical trials. Consequently, they were integrated in recent therapeutic guidelines, often replacing former standard drugs as first-line options.
Echinocandins have emerged as the generally preferred primary treatment in
candidemia. The expert panel of ESCMID views
fluconazole only as a marginally recommended
therapy for this indication. The use of
amphotericin B deoxycholate should be generally avoided because of toxicity.