ESCMID guideline for the diagnosis and management of Candida diseases 2012: non-neutropenic adult patients

Abstract

This part of the EFISG guidelines focuses on non-neutropenic adult patients. Only a few of the numerous recommendations can be summarized in the abstract. Prophylactic usage of fluconazole is supported in patients with recent abdominal surgery and recurrent gastrointestinal perforations or anastomotic leakages. Candida isolation from respiratory secretions alone should never prompt treatment. For the targeted initial treatment of candidaemia, echinocandins are strongly recommended while liposomal amphotericin B and voriconazole are supported with moderate, and fluconazole with marginal strength. Treatment duration for candidaemia should be a minimum of 14 days after the end of candidaemia, which can be determined by one blood culture per day until negativity. Switching to oral treatment after 10 days of intravenous therapy has been safe in stable patients with susceptible Candida species. In candidaemia, removal of indwelling catheters is strongly recommended. If catheters cannot be removed, lipid-based amphotericin B or echinocandins should be preferred over azoles. Transoesophageal echocardiography and fundoscopy should be performed to detect organ involvement. Native valve endocarditis requires surgery within a week, while in prosthetic valve endocarditis, earlier surgery may be beneficial. The antifungal regimen of choice is liposomal amphotericin B +/- flucytosine. In ocular candidiasis, liposomal amphotericin B +/- flucytosine is recommended when the susceptibility of the isolate is unknown, and in susceptible isolates, fluconazole and voriconazole are alternatives. Amphotericin B deoxycholate is not recommended for any indication due to severe side effects.

Fungicidal versus fungistatic therapy of invasive Candida infection in non-neutropenic adults: a meta-analysis

“…Overall, our analysis supports international recommendations that anti- Candida therapy with fungicidal activity but limited toxicity (i.e. echinocandins) should be preferred in seriously ill, adult non-neutropenic patients with invasive Candida infections (Bow et al 2010; Cornely et al 2012; Pappas et al 2015). …”

Bloodstream infections in the Intensive Care Unit

“…98 In order to achieve the goal of an early treatment of candidaemia, a pre-emptive antifungal therapy should be considered in critically ill patients with risk factors for candidaemia and positivity of (1-3)-b-D-glucan, when available. 99 Current European Society of Clinical Microbiology and Infectious Disease (ESCMID) guidelines recommend the use of echinocandins, due to their rapid fungicidal activity, the optimal anti-biofilm activity, the broader spectrum of activity, the lower resistance rates and the favorable safety profile, characterized by low toxicity and low drug-drug interactions compared with azoles. 99 …”

“…99 Current European Society of Clinical Microbiology and Infectious Disease (ESCMID) guidelines recommend the use of echinocandins, due to their rapid fungicidal activity, the optimal anti-biofilm activity, the broader spectrum of activity, the lower resistance rates and the favorable safety profile, characterized by low toxicity and low drug-drug interactions compared with azoles. 99 …”

Behandlung invasiver Mykosen

“…B. Aszites oder Pleurapunktat [3]. Eine solche zielgerichtete Therapie soll bis 14 Tage nach der ersten negativen Blutkultur fortgeführt werden.…”

“…Dieses Vorgehen beinhaltet jedoch ein zeitliches Problem, da der Kulturnachweis von Candida-Spezies mehrere Tage in Anspruch nehmen kann und das Sterberisiko für den Patienten mit einer unbehandelten invasiven Candida-Infektion täglich steigt [5]. Aus diesem Grund nennt die Leitlinie noch andere Therapiestrategien, die das Zeitproblem umgehen sollen [3]. Dazu gehören die prophylaktische Therapie (Behandlung von Patienten mit Risikofaktoren für eine invasive Candida-Infektion ohne Infektionszeichen), die empirische Therapie (Behandlung von Patienten mit Risikofaktoren für eine invasive Candida-Infektion mit Infektionszeichen) und die präempti-ve Therapie (Behandlung bei frühen diagnostischen Tests, die hinweisend auf invasive Candida-Infektionen sind, wie z.…”