Guidelines for Antifungal Therapy

Specifically, these hazards include the rising rates of echinocandin resistance and the concomitant development of multi-drug resistance worldwide. 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. Miscellaneous: Prophylaxis should be considered in adult intensive care units (ICUs) with a high rate (greater than 5%) of invasive candidiasis. Medicine (Baltimore). During that same time period, the medical center witnessed a nearly 3-fold rise in echinocandin resistance among clinical isolates of C.

AUC and C max reduced ~22% compared to normal hepatic function. 7 mg/kg daily (strong recommendation; moderate-quality evidence). Oral fluconazole, 200–400 mg (3–6 mg/kg) daily, for 14–21 days is recommended (strong recommendation; high-quality evidence). Catheter removal and incision and drainage or resection of the vein, if feasible, is recommended (strong recommendation; low-quality evidence). Anidulafungin compared with fluconazole in severely ill patients with candidemia and other forms of invasive candidiasis: IDSA Candidiasis guidelines suggest considering a transition to oral fluconazole therapy once oral intake tolerable. A third option for C. In the first section, the panel summarizes background information relevant to the topic.

HEALTH DISPARITIES MULTIPLE CHRONIC CONDITIO. Genitourinary: In meta-analyses of β-D-glucan studies, the pooled sensitivity and specificity for diagnosing invasive candidiasis were 75%–80% and 80%, respectively [144–146].

  • In contrast, the sensitivity of blood cultures was only 7%.
  • 2 If fluconazole susceptibility cannot be inferred by species identification, such as with C.
  • 7 mg per kg daily, for severely ill patients (A-III); after patient is stable, change to fluconazole (B-III) An echinocandin* for several weeks, followed by fluconazole (B-III) Transition from LFAmB or AmB-d to fluconazole is favored after several weeks in stable patients; duration of therapy is until lesions have resolved (usually months) and should continue through periods of immunosuppression (e.)
  • Systemic antifungal therapy is always required.
  • The number-needed-to-treat to prevent one death from any cause was 29 for the high-risk group compared with 63 for the lower-risk group, and baseline risk of all-cause mortality was approximately 2.
  • Vitrectomy should be considered to decrease the burden of organisms and to allow the removal of fungal abscesses that are inaccessible to systemic antifungal agents (strong recommendation; low-quality evidence).

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Denning et al. 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). Recommendations related to universal testing and in-depth treatment algorithms for hepatitis B virus are included in the ASCO Provisional Clinical Opinion on Hepatitis B Virus Screening for Patients With Cancer Before Therapy.

54 Baseline rates of fungal infections in the control groups were 7. Options include first-line fluconazle, an echinocandin, and daily bathing of ICU patients with chlorhexidne. 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. Ostrosky-Zeichner L, Oude Lashof AM, Kullberg BJ, et al. In adult patients, the plasma elimination half-life for fluconazole is approximately 30 h. Distinguishing gut-associated from vascular catheter–associated candidemia can be difficult in these patients [201]. Maertens J et al. • Electrolyte problems like mood changes, confusion, muscle pain or weakness, abnormal heartbeat, seizures, lack of appetite, or severe nausea or vomiting.

  • Age-related changes in immune function (so-called immunosenescence) have the potential to impact on response to antimicrobial treatment [14, 21].
  • Central venous catheters (CVCs) should be removed as early as possible in the course of candidemia when the source is presumed to be the CVC and the catheter can be removed safely; this decision should be individualized for each patient (strong recommendation; moderate-quality evidence).

International Journal of Infectious Diseases

However, it remains unclear when to initiate prophylaxis, empirical or pre-emptive therapy or when to step down. When neutropenia is protracted, an antifungal drug should be continued until engraftment. (5%) of 245) fulfilled at least one criterion for critical illness (anidulafungin, n = 89; fluconazole, n = 74). The IDSA SPGC will consider this input and determine the necessity and timing of an update. Patients frequently have questions about neutropenic diets or nutritional supplements; therefore, recommendations related to these topics should be included in patient materials. 11 A summary of the key recommendations contained within this guideline can be found in the Bottom Line box. Treatment; invasive disease: A systematic review was conducted to analyze available data generated in treatment trials and empiric therapy trials that enrolled neutropenic patients [205].

Candida infective endocarditis: 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. An exception is made for candidemia due to C. Ostrowsky B, Greenko J, Adams E, et al. Such a broad range of infections requires an equally broad range of diagnostic and therapeutic strategies. COST IMPLICATIONS GUIDELINE IMPLEMENTATION << ADDITIONAL RESOURCES REFERENCES ASCO guidelines are developed for implementation across health settings. Chronic suppressive therapy with fluconazole if the isolate is susceptible, for as long as the device remains in place is recommended (strong recommendation; low-quality evidence). Oral nystatin, 100 000 units 3 times daily for 6 weeks, is an alternative to fluconazole in neonates with birth weights <1500 g in situations in which availability or resistance preclude the use of fluconazole (weak recommendation; moderate-quality evidence).

Fluconazole, 800-mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) daily, is an alternative for patients who are not critically ill and have had no prior azole exposure (weak recommendation; low-quality evidence). Celgene, TG Therapeutics, Gilead Sciences, Genentech, AbbVie, Pharmacyclics, Novartis Research Funding: Cornely OA, Lasso M, Betts R, et al. Systemic antifungal agents shown to be effective for the treatment of invasive candidiasis comprise 4 major categories: What is the treatment for candidemia in neutropenic patients? Invasive fungal infections and approaches to their diagnosis.

Dosing: Pediatric

Initial therapy with lipid formulation AmB, 3–5 mg/kg daily OR an echinocandin (micafungin: )Figure 2 illustrates when TDM should be considered. This document summarizes current knowledge about treatment of multiple forms of candidiasis and is the guideline of the Infectious Diseases Society of America (IDSA) for the treatment of candidiasis. TG Therapeutics, Janssen Biotech, Celgene, AbbVie, Genentech, Karus Therapeutics Michelle Rajotte Consulting or Advisory Role: There has been a greater demand for antifungal susceptibility testing (AFST) in recent years as a result of the increased use of antifungals, the recognition of innate resistance in some fungal species, and the emergence of resistance during therapy. FDA allows marketing of the first test to identify five yeast pathogens directly from a blood sample [news release.

Currently, there are insufficient data to recommend the high-dose vaccine in compromised hosts younger than 65 years. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. 08; 95% CI, -0. The continued reliance on blood cultures, which are notoriously insensitive as markers of disease, remains a significant obstacle to early intervention for this condition.

AU - Schlamm, Haran T. 5 Pappas PG, Lionakis MS, Arendrup MC, Ostrosky-Zeichner L, Kullberg BJ. In these studies, baseline candidemia was cleared in 73% of those treated with AmB deoxycholate vs 82% of those treated with liposomal AmB [209] and in 67% of those treated with caspofungin vs 50% of those treated with liposomal AmB [210]. The information herein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. Preliminary analysis of the recently completed large international double-blind trial comparing isavuconazole to an echinocandin for invasive candidiasis suggests that isavuconazole did not meet criteria for noninferiority (personal communication, Astellas US). What is the treatment for oropharyngeal candidiasis? Reboli, Mindy G.

More About Micafungin

For patients who have nephrostomy tubes or stents in place, consider removal or replacement, if feasible (weak recommendation; low-quality evidence). Neutropenic patients LFAmB, 3 to 5 mg per kg daily; caspofungin (Cancidas), 70-mg loading dose, then 50 mg daily (A-I); or voriconazole, 400 mg (6 mg per kg) twice daily for two doses, then 200 mg (3 mg per kg) twice daily (B-I) Fluconazole, 800-mg (12-mg per kg) loading dose, then 400 mg (6 mg per kg) daily; or itraconazole, 200 mg (3 mg per kg) twice daily (B-I) In most neutropenic patients, it is appropriate to initiate empiric antifungal therapy after four days of persistent fever despite antibiotic use; serodiagnostic tests and computed tomography imaging may be helpful; azoles should not be used in patients with previous azole prophylaxis. Monitor closely and evaluate appropriateness of continued use in patients who develop abnormal liver function tests during treatment. Yearly influenza vaccination with inactivated quadrivalent vaccine is recommended for all patients receiving chemotherapy for malignancy. Further dilute 50 to 150 mg in 100 mL NS or D5W.


2020 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis. (4°F) sustained over a 1-hour period. As many patients for whom guideline recommendations apply present with MCCs, any treatment plan must take into account the complexity and uncertainty created by the presence of MCCs and highlight the importance of shared decision making regarding guideline use and implementation. 2020 Update by the Infectious Diseases Society of America.

Intravenous echinocandin (caspofungin:


In patients with severe renal insufficiency (glomerular filtration rate < 20 mL/min) the half-life increased to 98 h [44]. 53; 95% CI, 0. For this reason, among patient populations that are also at risk for invasive mold infections, such as hematopoietic cell transplant recipients, β-D-glucan offers a theoretical advantage over more narrow assays for candidiasis. The role of PCR in testing samples other than blood is not established. Because this organism appears to develop resistance quickly, patients on antifungal treatment should be carefully monitored for clinical improvement and follow-up cultures and repeat susceptibility testing should be conducted.

Candidiasis, Osteoarticular Infections

No significant differences were found in baseline characteristics between the two treatment groups. 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). Septic arthritis Fluconazole, 400 mg (6 mg per kg) daily for at least six weeks; or LFAmB, 3 to 5 mg per kg daily for several weeks, then fluconazole to completion (B-III) An echinocandin* or AmB-d, 0. A working knowledge of the local epidemiology and rates of antifungal resistance is critical in making informed therapeutic decisions while awaiting culture and susceptibility data. The infusion rate may be slowed for possible histamine-mediated infusion reactions. The ORWG is part of the CLSI Subcommittee on Antimicrobial Susceptibility Testing (AST) and was established in 2020. The activity of fluoroquinolone prophylaxis on the intestinal microbiome is to select not only for fluoroquinolone-resistant, gram-negative bacilli, but also for Clostridium difficile and enterococci.

Alternatives for fluconazole-refractory disease include an echinocandin (micafungin: )The overwhelming majority of studies have examined nonculture diagnostics in the setting of candidemia. In exceptional circumstances, where central nervous system involvement has been definitively ruled out, may consider use of echinocandins with caution at the following doses: More limited data on deep-seated candidiasis demonstrate how these tests may identify cases that are currently missed by blood cultures. Several studies demonstrated a relationship between the voriconazole plasma concentration and adverse effects, such as elevated liver enzymes and neurotoxicity including visual disturbances [38,39,40]. Concentration-dependent toxicity results in bone marrow suppression and hepatitis. 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. 16 by Clinical Infectious Diseases as an update to its 2020 guidelines.

Flucytosine is contraindicated during pregnancy because of fetal abnormalities observed in animals. In a meta-analysis of 14 studies, the sensitivity/specificity for the diagnosis of invasive candidiasis of mannan and antimannan IgG individually were 58%/93% and 59%/83%, respectively [140]. Candida auris Isolates Resistant to Three Classes of Antifungal Medications — New York, 2020.


The searches were finalized and delivered between late November 2020 and January 2020. The use of words like “must,” “must not,” “should,” and “should not” indicates that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating physician to select other courses of action in individual cases. 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]. 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. 2020/12/17 (4 years ago) - Updated:

5 × 109/L), and profound neutropenia as < 100/µL (equivalent to < 0. Moderate impairment (Child-Pugh class B): The sensitivity/specificity of 2 consecutive positive β-D-glucan results was 65%/78%. Advances in antifungal therapy. 7% (Yanni 2020); Adults:

We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. Initial searches were created and confirmed with input from the guideline committee chairs and group leaders from August to November 2020. For fluconazole-refractory disease, itraconazole solution, 200 mg once daily OR posaconazole suspension, 400 mg twice daily for 3 days then 400 mg daily, for up to 28 days are recommended (strong recommendation; moderate-quality evidence).

Empiric Antifungal Therapy (neutropenic Fever)

This information does not mandate any particular course of medical care. During treatment, it is recommended to repeat measurements of blood concentrations regularly, including after the start of treatment, dose adjustments, changed gastrointestinal absorption, changed interacting co-medication and changed clinical condition of the patient [56, 59]. 3 mg per kg daily (B-II) Fluconazole is recommended for patients with moderate to severe disease, and topical therapy with clotrimazole or nystatin is recommended for those with mild disease; uncomplicated disease should be treated for one to two weeks; for patients with refractory disease, itraconazole, voriconazole, posaconazole, or amphotericin B suspension is recommended. For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections (strong recommendation; high-quality evidence). However, the 2020 Infectious Diseases Society of America (IDSA) candidiasis guidelines recommend an echinocandin for the treatment of candidemia/invasive candidiasis in patients who are considered to be "moderately severe or severely" ill. The guideline recommendations were based on the review of evidence by the Expert Panel. Pooling of results favored use of nonpolyenes to AmB-containing comparators. Importantly, to appropriately interpret TDM, the susceptibility of the pathogen to the antifungal drug should be known as well.

The risk of infection increases with the depth and duration of neutropenia, with the greatest risk occurring in patients who experience profound, prolonged neutropenia after chemotherapy, which is most likely to occur in the period before engraftment during HSCT and after induction chemotherapy for acute leukemia. Since approximately 10%–20% of women harbor Candida spp. However, sensitivity of Candida isolates to echinocandins is decreasing, requiring higher doses and indicating that defined therapeutic ranges are required to perform TDM [66].

The typical dosage for lipid formulation AmB is 3–5 mg/kg daily when used for invasive candidiasis. The recommended oral dose is 9 mg/kg twice daily (maximum dose 350 mg) [95, 107]. A therapeutic range, however, is described for this drug (area under the concentration–time curve [AUC]/MIC > 100; 400 AUC mg·h/L; trough > 10–15 mg/L) [59]. Caspofungin and micafungin are approved by the US Food and Drug Administration (FDA) for use in children.