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Invasive candidiasis

What's new

The European Confederation for Medical Mycology (ECMM) has published a new guideline on the diagnosis and management of candidemia and invasive candidiasis. Conventional culture-based diagnosis is recommended despite its limited sensitivity. Biomarkers (e.g., serum β-D-glucan, mannan antigen, and anti-mannan antibody) are recommended only in conjunction with clinical findings, other biomarkers, or additional diagnostic methods. Echinocandins are the first-line therapy for candidemia, with triazoles (except itraconazole) and amphotericin B (liposomal or lipid complex) as alternatives. Treatment should continue for at least 14 days after the last positive blood culture. .

Background

Overview

Definition
Invasive candidiasis refers to bloodstream infection (candidemia) caused by Candida species that can lead to deep-seated infections including intra-abdominal abscess, peritonitis, and osteomyelitis.
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Pathophysiology
Invasive candidiasis is most frequently caused by C. albicans. Candidemia pathways include long-term use of antibiotics, gastrointestinal and cutaneous perforation (chemotherapy, gastric surgery, venous catheters), and immunosuppressive medication.
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Epidemiology
The incidence of invasive candidiasis in the US is estimated at 8 per 100,000 population per year, with peak rates at the extremes of age. Half of all invasive candidiasis cases occur in the ICU setting.
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Disease course
Clinical manifestations include unexplained fever nonresponsive to antibacterial treatment. Complications of candidemia can lead to ocular involvement (choroiditis, retinitis, endophthalmitis, and blindness), abdominal cavity (abdominal abscess, pancreatitis, peritonitis), bone (osteomyelitis, spondylodiscitis), brain (brain abscess, meningoencephalitis), heart (endocarditis), kidneys (candiduria, pyelonephritis, pyonephrosis, renal abscess), liver and spleen (chronic disseminated candidiasis, focal abscess), and lung (focal abscess). The disease decreases the QoL.
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Prognosis and risk of recurrence
Invasive candidiasis in the ICU setting is associated with a high mortality rate of 35-80%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of invasive candidiasis are prepared by our editorial team based on guidelines from the European Confederation of Medical Mycology (ECMM/ASM/ISHAM 2025), the U.S. Department of Health and Human Services (DHHS 2025), the American Thoracic Society (ATS 2024), the European Society of Intensive Care Medicine (ESICM/ESCMID 2019), and the Infectious Diseases Society ...
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Diagnostic investigations

History and physical examination: as per ASM/ECMM/ISHAM 2025 guidelines, obtain a detailed patient history, including host and risk factors, and perform a thorough physical examination focusing on potentially affected organs and vital signs in patients with suspected invasive candidiasis.
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  • Ophthalmological examination

  • Fungal culture

  • Antifungal susceptibility testing

  • Molecular tests

  • Biomarkers

  • Diagnostic imaging

Medical management

Antifungal therapy, empirical therapy: as per ASM/ECMM/ISHAM 2025 guidelines, initiate empirical antifungal treatment in patients with septic shock or patients with deteriorating conditions having additional risk factors for candidemia, such as a prolonged stay in an ICU, an indwelling vascular catheter, or colonization with Candida species.
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  • Antifungal therapy (echinocandins)

  • Antifungal therapy (triazoles)

  • Antifungal therapy (amphotericin B)

  • Antifungal therapy (second-line)

  • Step-down therapy

  • Duration of therapy

Therapeutic procedures

Catheter removal: as per ASM/ECMM/ISHAM 2025 guidelines, remove the central venous catheter as early as possible (< 48-72 hours) if in place.
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  • Abdominal drainage/debridement

  • Granulocyte transfusion

Specific circumstances

Neonatal patients, prophylaxis in NICU: as per IDSA 2016 guidelines, administer IV or PO fluconazole prophylaxis, 3-6 mg/kg twice weekly for 6 weeks, in neonates with birth weights < 1,000 g in nurseries with high rates (> 10%) of invasive candidiasis.
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  • Neonatal patients (invasive candidiasis and candidemia)

  • Neonatal patients (CNS candidiasis)

  • Critically ill patients

  • Patients with neutropenia

  • Patients with esophageal candidiasis (HIV-negative)

  • Patients with esophageal candidiasis (HIV-positive)

  • Patients with chronic disseminated candidiasis

  • Patients with intra-abdominal candidiasis

  • Patients with respiratory tract candidiasis

  • Patients with cardiovascular candidiasis

  • Patients with CNS candidiasis

  • Patients with osteoarticular candidiasis

  • Patients with ocular candidiasis

Preventative measures

Prophylaxis in ICU patients: as per ATS 2024 guidelines, avoid administering routine prophylactic or empiric antifungal therapy targeting Candida species in critically ill patients without neutropenia or a history of transplantation.
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  • Prophylaxis in neutropenia

  • Prophylaxis after allo-SCT

  • Prophylaxis after abdominal surgery