Clinical Pathways and Guidance

ECIL guidelines for the diagnosis of Pneumocystis jirovecii pneumonia in patients with haematological malignancies and stem cell transplant recipients. Centers for Disease Control and Prevention. 1 Neutrophils are critical for providing host defense against infection, particularly bacterial and fungal infection. Candida fungi can cause a wide variety of infections, including of the mouth, tongue, vagina and esophagus, but candidiasis most often is invasive, involving deep tissues. Reboli AC, Rotstein C, Pappas PG, et al. • Hepatic impairment:

For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections (strong recommendation; high-quality evidence). The 3 lipid formulation AmB agents have different pharmacological properties and rates of treatment-related adverse events and should not be interchanged without careful consideration. This may mean that some or all of the recommended care options are modified or not applied, as determined by best practice in consideration of any MCC. For anti-infective drugs, including antifungal agents, it is both difficult and time-consuming to assess directly whether the infection is adequately treated [57]. Yearly influenza vaccination with inactivated quadrivalent vaccine is recommended for all patients receiving chemotherapy for malignancy. What is the treatment for candidemia in nonneutropenic patients?

Non-HIV-exposed/-positive: Both voriconazole and fluconazole inhibit CYP3A4 and display many drug–drug interactions, resulting in a potential increase of adverse events when compared with the echinocandins [36]. TDM can be performed to guide dosing of antifungal drugs [58, 59]. Fluconazole, itraconazole, posaconazole, and isavuconazole should be avoided in pregnant women, especially those in the first trimester, because of the possibility of birth defects associated with their use. Flucytosine may be added to the treatment for specific patient groups, including those with central nervous system (CNS) candidiasis and urinary tract infections [2]. • Injection-site reactions:

The role of the microbiology laboratory. There is an abundance of clinical data generated from large randomized clinical trials for candidemia, Candida esophagitis, oropharyngeal candidiasis, and prophylaxis studies in special populations, such as patients in intensive care units (ICUs), neonates, and selected transplant recipients, and these studies have led to important insights into optimal therapeutic approaches in these vulnerable populations. ESCMID and ECMM joint clinical guidelines for the diagnosis and management of systemic phaeohyphomycosis: CLINICAL QUESTION 1 Antibacterial Prophylaxis. Data among patients colonized with Candida were surprisingly limited, but there was a trend toward lower specificity.

Switching to a liposomal amphotericin B (5 mg/kg daily) could be considered if the patient is clinically unresponsive to echinocandin treatment or has persistent fungemia for >5 days. Adults receiving bone marrow or peripheral stem-cell transplantation: Candida peritonitis. Posaconazole suspension, 400 mg twice daily, or extended-release tablets, 300 mg once daily, could be considered for fluconazole-refractory disease (weak recommendation; low-quality evidence). Severe anaphylactic reactions, including shock, have been reported. 09); however, there was a significant effect for death related to fungal infection (RR, 0.

For fluconazole-refractory disease, itraconazole solution, 200 mg daily, OR voriconazole, 200 mg (3 mg/kg) twice daily either intravenous or oral, for 14–21 days is recommended (strong recommendation; high-quality evidence).

Executive Summary

Summarized below are the 2020 revised recommendations for the management of candidiasis. Voriconazole versus a regimen of amphotericin B followed by fluconazole for candidaemia in non-neutropenic patients: IDSA has published more than 50 treatment guidelines on various conditions and infections, ranging from HIV/AIDS to Clostridium difficile. 5 mg/kg/day for invasive aspergillosis (Denning 2020; Emiroglu 2020; Flynn 2020; Singer 2020). 10 For more specific guidelines on the prevention and treatment of infections in stem-cell transplant recipients, the reader is advised to consult American Society for Blood and Marrow Transplantation/IDSA guidelines. Yeast infections, use of antibiotics. (200 mg daily) for 14–21 days, OR AmB deoxycholate, 0. Endocrine & metabolic:

If your society or organization has guidelines that you would like to have listed here, please contact the ESCMID Guidelines Director. A mold-active triazole is recommended where the risk of invasive aspergillosis is > 6%, such as in patients with AML/MDS during the neutropenic period associated with chemotherapy. USPSTF Guidelines:

45 Clinicians must be mindful of the clinical syndromes associated with these pathogens and appropriately tailor their therapeutic approaches.

Emerging Infections

Caspofungin, anidulafungin, and micafungin are available only as parenteral preparations [82–84]. This updated version of the guideline continues to endorse this recommendation (Table 1). Toxicity appears to be reduced for the lipid formulations (liposomal amphotericin B and amphotericin B lipid complex) [51,52,53]. Recommendation 1. Lipid formulations of AmB are more expensive than AmB deoxycholate, but all have considerably less nephrotoxicity [42, 43].

In this setting, especially if the patient has been treated previously with an azole antifungal agent, the possibility of microbiological resistance must be considered. The azole agents demonstrate activity against most Candida species. 1 to 3 mg/kg daily; maximum dose: ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose.

3°C (101°F) or a temperature of ≥ 38.


The data for catheter removal are less compelling, and catheter removal often creates significant intravenous access problems. In these trials, 50% of caspofungin recipients vs 40% of AmB deoxycholate recipients [25], 68% of micafungin recipients vs 61% of liposomal AmB recipients [26], and 69% of micafungin recipients vs 64% of caspofungin recipients [28] with neutropenia at onset of therapy were successfully treated. For itraconazole, when measured by high-pressure liquid chromatography (HPLC), both itraconazole and its bioactive hydroxy-itraconazole metabolite are reported, the sum of which should be considered in assessing drug levels. Uptodate, these problems require a different treatment than the anti-fungal medicine given for a yeast infection. Figure 2 illustrates when TDM should be considered. Several authors have demonstrated that mortality is closely linked to both timing of therapy and/or source control [14–19].

The domain ‘clarity of presentation’ received the highest scores (88%) and ‘applicability’ the lowest (18%). The IDSA and ESCMID guidelines recommend fluconazole in patients who are not critically ill and are considered unlikely to be infected with an azole-resistant species. Systemic candidiasis in intensive care units:

Pharmacodynamic and Pharmacokinetic Considerations in the Elderly

Candidiasis is commonly treated with antimycotics; these antifungal drugs include topical clotrimazole, topical nystatin, fluconazole, and topical ketoconazole. Infants ≥4 months, Children, and Adolescents: The use of amphotericin B deoxycholate is limited by its toxicity, including infusion-related reactions, hepatotoxicity, haematological effects and nephrotoxicity [47]. Electrolyte disturbances may be exacerbated by co-administration of thiazides and loop diuretics.

Mycology Resources

For best results, please make sure your browser is accepting cookies. Recommended duration of therapy for candidemia without obvious metastatic complications is for 2 weeks after documented clearance of Candida species from the bloodstream and resolution of symptoms attributable to candidemia (strong recommendation; moderate-quality evidence). The updated guidelines recommend the medication switch because newer research shows that in invasive infections, echinocandins -- which kill the fungus -- are more effective than fluconazole -- which prevents the fungus from growing. An alternative regimen is liposomal AmB, 5 mg/kg daily (strong recommendation; low-quality evidence). (86), whereas this outcome was uncertain in the solid tumors group because of a low number of events.

Among patients with suspected azole- and echinocandin-resistant Candida infections, lipid formulation AmB (3–5 mg/kg daily) is recommended (strong recommendation; low-quality evidence).

A recent multicenter point-prevalence survey identified Candida species as the most commonly isolated healthcare-associated bloodstream pathogen [4]. Both recurrent and persistent C. The one must-do if you’re itching down there. This feature is still in beta so some features may not be available at this time, but check it out! Outcomes are particularly poor in people with protracted neutropenia, such as that which develops after induction therapy for hematologic malignancies [190, 203, 204].

729-59, table of contents.

Full Recommendations

With macular involvement, antifungal agents as noted above PLUS intravitreal injection of either AmB deoxycholate, 5–10 µg/0. It has not been well studied for invasive candidiasis, and is generally reserved for patients with mucosal candidiasis, especially those who have experienced treatment failure with fluconazole [60]. The role of PCR in testing samples other than blood is not established. A CVC is present in at least 70% of nonneutropenic patients with candidemia at the time that the diagnostic blood culture is obtained [5, 7–9, 170, 184–187].

  • COST IMPLICATIONS GUIDELINE IMPLEMENTATION ADDITIONAL RESOURCES REFERENCES This updated guideline includes the latest evidence on prophylaxis for immunosuppressed adult patients undergoing treatment of malignancy.
  • A third option for C.
  • An updated systematic review of antibiotic prophylaxis for bacterial infections in afebrile neutropenic patients after chemotherapy included 109 studies that compared antibiotic prophylaxis options with each other or placebo or no intervention.
  • Posaconazole does not have an indication for primary candidiasis therapy.

Further Information

The IDSA SPGC will consider this input and determine the necessity and timing of an update. Most observers agree that lipid formulations, with the exception of ABCD, have fewer infusion-related reactions than AmB deoxycholate. Abnormal alanine aminotransferase (pediatric: )

For now, TDM could be considered for the echinocandins or amphotericin B if patients do not respond to treatment, based on the effective pharmacokinetic/pharmacodynamic (PK/PD) parameters from in vivo studies [69]. All panel members were selected on the basis of their expertise in clinical and/or laboratory mycology with a focus on candidiasis. Thus, clinicians must carefully consider the influence on a patient's drug regimen when adding or removing an azole.

  • An exception is made for candidemia due to C.
  • There is limited pharmacokinetic information that is directly relevant to frail older people, with multiple health problems, organ dysfunction and polypharmacy.
  • Oral formulations are dosed in adults at 200 mg 3 times daily for 3 days, then 200 mg once or twice daily thereafter.
  • Fluconazole, 800-mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) daily, is an acceptable alternative for patients who have had no recent azole exposure and are not colonized with azole-resistant Candida species (strong recommendation; moderate-quality evidence).
  • Invasive infections can develop at any point after patients become colonized.
  • For more information about ASCO's conflict of interest policy, please refer to www.
  • CLSI supplement M60.

Main Digest

Yearly influenza vaccination with inactivated vaccine is recommended for all patients receiving chemotherapy for malignancy and all family and household contacts and health care providers. COST IMPLICATIONS Section: 94; 95% CI, 0. In the first section, the panel summarizes background information relevant to the topic. Fungal skin infections, 6) Chronic Mucocutaneous Candidiasis (Candida Granuloma). For this updated version of the guideline, antiviral prophylaxis recommendations are also included and good practice recommendations related to vaccinations are outlined.

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

An Update on the Candidiasis Infection Guidelines

Currently, there are insufficient data to recommend the high-dose vaccine in compromised hosts younger than 65 years. Yeast infection, dry vagina could be caused by antibiotics, cold meds, that’s according to the Centers for Disease Control and Prevention. Are precautions such as neutropenic diet, etc. Barriers to implementation include the need to increase awareness of the guideline recommendations among front-line practitioners and survivors of cancer and caregivers, and also to provide adequate services in the face of limited resources. Patients whose blood stream infections are caused by Candida are more likely to die.

The therapeutic trough concentration window for voriconazole is 1–5. 6,7 The Expert Panel (Appendix Table A1, online only) met via teleconference and/or Webinar and corresponded through e-mail. Flucytosine demonstrates broad antifungal activity against most Candida species, with the exception of C. Patients who become colonized with C. As a class, these agents are generally well-tolerated. A retrospective review of the medical records of 740 patients with melanoma who received immune checkpoint blockers found that serious infection occurred in 54 patients (7. )GUIDELINE QUESTIONS Section: If the prosthetic device cannot be removed, chronic suppression with fluconazole, 400 mg (6 mg/kg) daily, if the isolate is susceptible, is recommended (strong recommendation; low-quality evidence).

(7) Recommendation 3.


(200-mg loading dose, then 100 mg daily) OR intravenous AmB deoxycholate, 0. 6 mg/kg daily, for 1–7 days is recommended (strong recommendation; low-quality evidence). 6 mg per kg for one to seven days; or flucytosine, 25 mg per kg four times daily for seven to 10 days (B-III) Alternative therapy is recommended for patients with fluconazole-resistant organisms; AmB-d bladder irrigation is recommended only for patients with refractory fluconazole-resistant organisms (e. )If you know of other recently published guideslines that should be included, please let us know. Dose adjustments for the echinocandins are not required for older patients. The development of reliable nonculture assays is critical to providing the opportunity for earlier intervention and more targeted antifungal therapy among large numbers of patients in whom traditional blood cultures are insensitive or provide untimely results [20]. Therefore, treatment with flucytosine should always be combined with another antifungal agent such as amphotericin B.

There is marked heterogeneity among studies in how they address these issues, as well as in patient and control populations, range and type of fungal pathogens targeted, invasive candidiasis disease entities, distributions of Candida species, prior antifungal use, specific β-D-glucan assays employed, and other aspects of study design and statistical interpretation. According to the guidelines, empiric therapy is not recommended for patients with an anticipated duration of neutropenia <10 days, unless other findings indicate a suspected invasive fungal infection. It is intuitive that each patient with candidemia must be managed individually with respect to CVC removal or retention, but on balance, the bulk of data supports an approach that leads to early removal among nonneutropenic patients in whom the catheter is a likely source of infection. What is the treatment for Candida endophthalmitis? The guidelines note that intensive care unit physicians should suspect candidiasis in patients who are deteriorating without an obvious reason, have unexplained fever, have an elevated white blood cell count, have a central venous catheter or recently had abdominal surgery.

Candida tropicalis possesses a remarkable capacity to form biofilms in medical devices.

This revised guideline reaffirms this recommendation, including antifungal prophylaxis with an oral triazole or parenteral echinocandin in the case of a population level risk of Candida infection > 10% and a mold-active triazole when the population level risk of aspergillosis is > 6%. 08; 95% CI, -0. Candidemia in the critically ill patient. For fluconazole-/voriconazole-resistant isolates, liposomal AmB, 3–5 mg/kg intravenous daily, with or without oral flucytosine, 25 mg/kg 4 times daily is recommended (strong recommendation; low-quality evidence). Species distribution is also a significant challenge for all forms of candidiasis, and there is considerable geographic, center-to-center, and even unit-to-unit variability in the prevalence of pathogenic Candida species [8–12]. A serum β-D-glucan assay (Fungitell; Associates of Cape Cod, East Falmouth, Massachusetts) has been approved by the FDA as an adjunct to cultures for the diagnosis of invasive fungal infections.

The new guidelines specified a two-week duration of empiric therapy in patients who improve and describe an approach to de-escalation in patients with no clinical response after 4-5 days of therapy, no evidence of invasive candidiasis, or a negative non-culture based diagnostic assay with a high negative predictive value.


This information should not be used to decide whether or not to take this medicine or any other medicine. Decreased urine output (pediatric: )Two main studies20,47 provided the majority of the data for that analysis, and no large studies of similar significance have been found in this guideline update. Asymptomatic cystitis Therapy not usually indicated, unless patient is at high risk (e. )Shah CP, McKey J, Spirn MJ, et al. Voriconazole does not accumulate in active form in the urine and thus should not be used for urinary candidiasis. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Antimicrobial Prophylaxis for Adult Patients With Cancer-Related Immunosuppression: When there is no clinical breakpoint established, the epidemiologic cutoff value (ECV) based on an examination of the distribution of MICs within a species can be used.

Chandrasekar PH, Sobel JD. The duration of treatment should be at least 4–6 weeks, with the final duration dependent on resolution of the lesions as determined by repeated ophthalmological examinations (strong recommendation; low-quality evidence). Lipid formulation AmB, 3–5 mg/kg daily, for 2 weeks, followed by fluconazole, 400 mg (6 mg/kg) daily, for at least 4 weeks is a less attractive alternative (weak recommendation; low-quality evidence). True-positive results are not specific for invasive candidiasis, but rather suggest the possibility of an invasive fungal infection. Similar to the approach in nonneutropenic patients, the recommended duration of therapy for candidemia in neutropenic patients is for 14 days after resolution of attributable signs and symptoms and clearance of the bloodstream of Candida species, provided that there has been recovery from neutropenia. The patients (163 (66. )Amphotericin B is a polyene isolated from Streptomyces nodosus.

  • If treatment is indicated, fluconazole is usually prescribed.
  • While a person’s numerical age is a poor guide to dosing, most patients are considered in the ‘elderly’ cohort at the age of 65 years and above.
  • January 17, 2020.
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  • The panel met face-to-face twice and conducted a series of conference calls over a 2-year period.
  • Anidulafungin is not hepatically metabolised and caspofungin and micafungin undergo minimal degradation by CYP isoenzymes.

Antimicrobial Stewardship

Maertens J et al. Chronic suppressive antifungal therapy with fluconazole, 400–800 mg (6–12 mg/kg) daily, is recommended to prevent recurrence (strong recommendation; low-quality evidence). COST IMPLICATIONS GUIDELINE IMPLEMENTATION ADDITIONAL RESOURCES REFERENCES Patients undergoing cytotoxic chemotherapy and hematopoietic stem-cell transplantation (HSCT) are at risk for infection, particularly during the period of neutropenia. PubMed, which includes Medline (1946 to present), was searched to identify relevant studies for the Candida guideline PICO (population/patient, intervention/indicator, comparator/control, outcome) questions. Combined treatment with both drugs should therefore be limited to specific cases, such as cryptococcosis. In all cases, the selected course of action should be considered by the treating provider in the context of treating the individual patient. Figure 1 provides a summary of the major factors influencing individualised dose selection in older people to achieve optimal health outcomes from antifungal treatment [11,12,13,14]. 70-mg loading dose, then 50 mg daily; micafungin:

Among neutropenic patients, the role of the gastrointestinal tract as a source for disseminated candidiasis is evident from autopsy studies, but in an individual patient, it is difficult to determine the relative contributions of the gastrointestinal tract vs the CVC as the primary source of candidemia [195, 201]. Blot SI, Vandewoude KH, De Waele JJ. J Microbiol Immunol Infect. The strength assigned to a recommendation chiefly reflects the panel's confidence that the benefits of following the recommendation are likely to outweigh potential harms. For example, false-positive results are rare in healthy controls, but decidedly more common among patients in an ICU [148]. GlyPharma Consulting or Advisory Role: Fluconazole, which is active against yeast but not mold, has for the most part been effective in reducing the risks of the former, but not the latter. 67; 95% CI, 0.

Details are available in the 2020 IDSA Clinical Practice Guideline for the Management of CandidiasisExternal. This information is not all inclusive; please refer to the guideline for further details. However, conclusions may be limited by significant enrollment bias of selected patients. With the new interpretation, the susceptible value has been reduced to ≤2 mg/L for C. Micafungin versus liposomal amphotericin B for candidaemia and invasive candidosis: This assay is not used widely in the United States, and its role in the diagnosis and management of invasive candidiasis is unclear. Multicenter evaluation of the Candida albicans/Candida glabrata peptide nucleic acid fluorescent in situ hybridization method for simultaneous dual-color identification of C.

150 mg once daily; treatment duration:


The basis for TDM is widely variable concentrations among patients and a strong relationship between concentration and efficacy and/or toxicity. While the quality of evidence is an important factor in choosing recommendation strength, it is not prescriptive. 13 In addition, a guideline implementation review was conducted. ECIL guidelines for treatment of Pneumocystis jirovecii pneumonia in non-HIV-infected haematology patients. How to treat vaginal yeast infection: otc medications & side effects. Empirical fluconazole versus placebo for intensive care unit patients: