The Bottom Line: “Antifungal therapy is recommended for all cases of [catheter-related bloodstream infection] CRBSI due to Candida species, including cases in which clinical manifestations of infection and/or candidemia resolve after catheter withdrawal and before initiation of antifungal therapy” (Mermel)
“Fluconazole administered at a dosage of 400 mg daily for 14 days after the first negative blood culture result is obtained is equivalent to amphotericin B in the treatment of candidemia caused by Candida albicans and azole-susceptible strains [184]. For Candida species with decreased susceptibility to azoles (e.g., C. glabrata and C. krusei), echinocandins (caspofungin administered with a 70-mg intravenous loading dose, followed by 50 mg daily administered intravenously; micafungin at a dosage of 100 mg daily administered intravenously or anidulafungin with a 200-mg intravenous loading dose followed by 100 mg daily administered intravenously) or lipid formulations of amphotericin B (ambisome or amphotericin B lipid complex) administered intravenously at a dosage of 3–5 mg/kg daily are highly effective [185–187]. Conventional amphotericin B therapy is also effective but is associated with more adverse effects.” (Mermel)
“The administration of appropriate antimicrobial treatment more than 12 h after the first positive blood sample for culture is drawn is associated, at least by multivariable analysis, with hospital mortality. This underscores the clinical importance of providing early appropriate treatment to patients with fungal bloodstream infections. Future studies are needed to define the optimal strategy for the empiric treatment of fungal bloodstream infections. Until such data become available, clinicians may consider the use of empiric antifungal therapy in patients at high risk for this infection to avoid delays in treatment.” (Morrell)
“The only treatment independently associated with lower hospital mortality for the entire patient cohort was early broad-spectrum antibiotic treatment (treatment within 1 hour vs no treatment within first 6 hours of diagnosis). Our findings in septic shock attributed to Candida infection support the importance of early appropriate therapy as a determinant of patient outcome. Given the overall importance of early appropriate therapy of septic shock attributed to Candida infection as an outcome determinant, clinical strategies facilitating the attainment of this goal are needed.” (Kollef)
Mermel, Leonard A et al. “Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America.” Clinical infectious diseases : an official publication of the Infectious Diseases Society of America vol. 49,1 (2009): 1-45. Free Full Text.
Morrell, Matthew et al. “Delaying the empiric treatment of candida bloodstream infection until positive blood culture results are obtained: a potential risk factor for hospital mortality.” Antimicrobial agents and chemotherapy vol. 49,9 (2005): 3640-5. Free Full Text.
Kollef, Marin et al. “Septic shock attributed to Candida infection: importance of empiric therapy and source control.” Clinical infectious diseases : an official publication of the Infectious Diseases Society of America vol. 54,12 (2012): 1739-46. Full Text at Emory.
The Bottom Line 