The Infectious Diseases Society of America (IDSA) last updated their guideline on the management of candidiasis in 2009. Since that time, new data have emerged on the diagnosis, prevention, and treatment of this major cause of morbidity and mortality, leading to an update to IDSA’s recommendations that was recently released.
“Among the most important studies during this time were those that assessed first-line therapy with echinocandins versus azoles,” says Peter G. Pappas, MD, lead author of the guideline update. This new research shows that echinocandins—which kill the fungus—are more effective than azoles—which prevent the fungus from growing—in treating invasive infections. “The data support our key recommendation to start most patients with candidiasis on echinocandins and then step down to an azole.”
The updated guideline also addresses the importance of judiciously using prophylaxis. It is important to understand which patient populations are mostly likely to benefit from prophylaxis, including ICU patients and transplant recipients. ICU patients who stand to benefit most from prophylaxis include patients:
- Who have been on antibiotics.
- Have central venous catheters.
- Are on a ventilator.
- Have pancreatitis or recent abdominal surgery.
- Are immunosuppressed.
- Have skin burns.
“Transplant patients who would benefit most from prophylaxis include high-risk liver transplant recipients, those with modified renal function, and those with prolonged operations who require blood products,” adds Dr. Pappas. Clinicians are also advised to suspect candidiasis in patients who are deteriorating without an obvious reason, have unexplained fever, and have elevated white blood cell counts.
The Importance of Early Care
A key theme throughout the guideline update is the importance of early recognition and initiation of therapy for candidiasis. “The data support early therapy as opposed to watchful waiting with regard to outcomes,” says Dr. Pappas. “Candidiasis is a growing issue, and we need to initiate therapy as soon as possible whenever it is suspected. Unfortunately, there aren’t many available diagnostic tests for the infection. One that looks promising is the T2Candida Panel, which requires no blood culture and can deliver results in as little as 3 hours. Clinicians need better access to these types of diagnostic tests and should use them more broadly than how they’re currently being used.”
Until specific, rapid diagnostic tests for candidiasis are more widely available, the guideline update recommends that primary care providers consult with infectious disease specialists to make an accurate diagnosis and initiate proper therapy. “The data on candidiasis are limited, but studies suggest that patients have better outcomes when an infectious disease specialist is involved,” says Dr. Pappas. “Clinicians should understand that methods for treating these infections are changing, and infectious disease specialists are in a position to share this information with their colleagues in the community.”
Pappas P, Kauffman C, Andes D, et al. Clinical practice guidelines for the management candidiasis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. 2015, December 16 [Epub ahead of print]. Available at http://cid.oxfordjournals.org/content/early/2015/12/15/cid.civ933.full.
Pappas P, Kauffman C, Andes D, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;48:503-535.
Pappas P, Rex J, Lee J, et al. A prospective observational study of candidemia: epidemiology, therapy, and influences on mortality in hospitalized adult and pediatric patients. Clin Infect Dis. 2003;37:634-643.
Pfaller M, Neofytos D, Diekema D, et al. Epidemiology and outcomes of candidemia in 3648 patients: data from the Prospective Antifungal Therapy (PATH Alliance(R)) registry, 2004-2008. Diagn Microbiol Infect Dis. 2012;74:323-331.