Synopsis
Separate colonisation and superficial candidiasis from invasive disease, obtain cultures and source control promptly, deliver species- and susceptibility-directed antifungal therapy, and contain transmissible Candidozyma auris safely.
- Candida commonly colonises the mouth, bowel, genital tract and skin; growth from sputum, a chronic wound or an asymptomatic urinary specimen usually does not prove invasive disease.
- Candidemia is never dismissed as a contaminant. Take blood cultures before antifungal therapy when safe and immediately assess intravascular lines, abdomen, urinary instrumentation, heart, eyes and other metastatic sites.
- First-line treatment for most critically ill adults with candidemia is an intravenous echinocandin, selected from anidulafungin, micafungin or caspofungin according to local formulary.
- Anidulafungin has a usable adult regimen of 200 mg intravenously once, then 100 mg intravenously every 24 hours.
- Step down to oral fluconazole only after clinical stability, documented bloodstream clearance, a susceptible species and a controlled source; fluconazole is not a safe automatic first dose for every patient.
- Repeat blood cultures daily or on alternate days until clearance and treat uncomplicated candidemia for at least 14 days after the first negative culture and resolution of attributable symptoms.
- Candida biomarkers such as serum 1,3-beta-D-glucan support but do not independently establish disease; tissue histology, culture and molecular testing are important in deep infection.
- For C. auris, do not treat colonisation, use an echinocandin empirically for symptomatic infection, obtain susceptibility testing and apply contact precautions, isolation or cohorting and effective environmental disinfection.
Key red flags
Shock, rising lactate, acute kidney injury, respiratory failure or altered consciousness with candidemia requires immediate critical-care and infection-specialist involvement.
Persistent positive blood cultures despite active therapy suggests an infected line, undrained focus, endocarditis, deep-organ disease or antifungal resistance.
Visual change, eye pain or photophobia during candidemia raises concern for ocular involvement and needs urgent ophthalmic assessment.
New murmur, embolic lesions, persistent bacteraemia or intracardiac material suggests Candida endocarditis and requires echocardiography plus surgical discussion.
Candidozyma auris identification or credible overseas-healthcare exposure requires immediate infection-prevention action even if the isolate represents colonisation rather than infection.
Neutropenia, pregnancy, CNS infection and hepatosplenic candidiasis materially alter diagnostic yield, drug choice, duration and specialist ownership.
Persistent fever, rigors or sepsis despite antibacterial therapy may be the only early presentation, particularly with a central line or abdominal source.
Ongoing peritonitis, anastomotic leak, pancreatitis, abscess or recurrent postoperative sepsis can represent invasive Candida even when blood cultures remain negative.
Investigation priorities
Recover Candida from blood, establish species and begin the clearance clock for treatment duration.
Management branches
A high-risk patient has unexplained sepsis, persistent fever or yeast signalled in a blood-culture bottle.
- Take peripheral and catheter blood cultures, complete sepsis bloods and sample the most credible source before antifungal treatment if collection will not create harmful delay.
- Start an intravenous echinocandin promptly for unstable or high-risk disease, using an exact local formulary regimen and obtaining microbiology, infection and pharmacy input.
- Review every intravascular catheter, urinary device, abdominal drain and operative site; remove or exchange an implicated central line when feasible and drain collections urgently.
- Identify species and susceptibility, repeat cultures until clear, and search for ocular, cardiac or deep-organ spread when symptoms, persistence or host factors justify it.
Candidemia or invasive candidiasis is confirmed or strongly suspected in an adult without a site requiring superior CNS, eye or urinary penetration.
- Give anidulafungin 200 mg intravenously once then 100 mg every 24 hours, micafungin 100 mg intravenously every 24 hours, or caspofungin 70 mg once then 50 mg every 24 hours according to local policy.