Diagnosis and therapy of Candida infections: joint recommendations of the German Speaking Mycological Society and the Paul-Ehrlich-Society for Chemotherapy

Abstract

Invasive Candida infections are important causes of morbidity and mortality in immunocompromised and hospitalised patients. This article provides the joint recommendations of the German-speaking Mycological Society (Deutschsprachige Mykologische Gesellschaft, DMyKG) and the Paul-Ehrlich-Society for Chemotherapy (PEG) for diagnosis and treatment of invasive and superficial Candida infections. The recommendations are based on published results of clinical trials, case-series and expert opinion using the evidence criteria set forth by the Infectious Diseases Society of America (IDSA). Key recommendations are summarised here: The cornerstone of diagnosis remains the detection of the organism by culture with identification of the isolate at the species level; in vitro susceptibility testing is mandatory for invasive isolates. Options for initial therapy of candidaemia and other invasive Candida infections in non-granulocytopenic patients include fluconazole or one of the three approved echinocandin compounds; liposomal amphotericin B and voriconazole are secondary alternatives because of their less favourable pharmacological properties. In granulocytopenic patients, an echinocandin or liposomal amphotericin B is recommended as initial therapy based on the fungicidal mode of action. Indwelling central venous catheters serve as a main source of infection independent of the pathogenesis of candidaemia in the individual patients and should be removed whenever feasible. Pre-existing immunosuppressive treatment, particularly by glucocorticosteroids, ought to be discontinued, if feasible, or reduced. The duration of treatment for uncomplicated candidaemia is 14 days following the first negative blood culture and resolution of all associated symptoms and findings. Ophthalmoscopy is recommended prior to the discontinuation of antifungal chemotherapy to rule out endophthalmitis or chorioretinitis. Beyond these key recommendations, this article provides detailed recommendations for specific disease entities, for antifungal treatment in paediatric patients as well as a comprehensive discussion of epidemiology, clinical presentation and emerging diagnostic options of invasive and superficial Candida infections.

International guidelines: the need to standardize the management of candidaemia

“…[1] Several guidelines relating to its management were published between 2009 and 2013 [2][3][4][5][6] and as demonstrated in a recent critique, the guidelines differ significantly from each other. [7] These inconsistencies lead to clinical uncertainty.…”

“…In this editorial, we elucidate the problem as it may occur in clinical practice. To determine the extent of variation among the five official guidelines [2][3][4][5][6] for the management of candidiasis, we collected data on all adult patients with proven candidaemia from 2011-2014. These examples from clinical practice show that attempts should be made to standardize the management of candidaemia.…”

“…Thus, adherence to the recommendations of the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) and Brazilian Guidelines for the Management of Candidiasis (BZL) was modest (69.8%), as these guidelines prefer echinocandin therapy in all patients, [5,6] while adherence to German Speaking Mycological Society and the Paul-Ehrlich Society for Chemotherapy (GSMS-PES) guideline was very high (51 out of 53; 96.2%) as both fluconazole and echinocandin are offered as primary therapy in this guidance. [4] The Infectious Diseases Society of America (IDSA) and the Canadian Clinical Practice (CCP) guidelines recommend risk stratification to determine which patients should receive echinocandin. The IDSA recommends echinocandins in the subset of patients with diabetes, cancer, hemodynamic instability, advanced age, or previous azole use while the CCP guidelines consider hemodynamic instability as the predominant risk factor.…”

“…The majority (n ¼ 23) of our patients were switched to fluconazole between days 3 and 9 which is broadly in line with the GSMS-PES guidance. [4] We were fully compliant with the CCP and the BZL guidelines which make no recommendations in relation to timing of step down. [3,6] Our compliance varied between 14.8 and 100% depending on the audit standard.…”

“…[5] However, since we carried out TOE in the two patients who had persistent candidaemia, we were 100% compliant with the GSMS-PES guidance. [4] Interestingly, the endocarditis guideline from the British Society for Antimicrobial Chemotherapy (BSAC) recommends TTE and not TOE as the initial diagnostic modality. [11] The length of treatment for our patients was variable.…”