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Candidiasis Organism-Specific Therapy

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
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.

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

See the list below:

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

Recurrent vulvovaginal candidiasis
:

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

Chronic disseminated candidiasis

See the list below:

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

See the list below:

Common organisms: C albicans, C glabrata, C tropicalis, C krusei, C parapsilosis

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

See the list below:

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

Nonneutropenia patients:

Fluconazole 800 mg loading dose, then 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

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

Neutropenia patients:

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

LFAmB 3-5mg/kg IV daily or

Fluconazole 800 mg loading dose, then 400 mg daily or

Voriconazole 400 mg BID for 2 doses, then 200 mg BID

Duration of therapy: 14d after blood cultures are sterile

Candida from bronchoalveolar lavage or respiratory secretions

See the list below:

Common organisms: C albicans, C glabrata, C tropicalis, C krusei, C parapsilosis

Therapy generally not recommended

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