Red Flags
- Candidaemia with septic shock or organ failure — empirical echinocandin within 1 hour; remove central venous catheter where feasible[1]
- C. auris isolated — multi-drug-resistant; isolate, contact precautions, infectious disease consult; resistance pattern dictates therapy[1]
- Endocarditis or endophthalmitis from candidaemia — extended treatment (≥6 weeks endocarditis), possible surgical valve replacement, ophthalmology evaluation in all candidaemia[1]
- Disseminated candidiasis with new visual symptoms — endogenous endophthalmitis; urgent dilated fundus exam[1]
First-line treatment
Interventions
- Remove indwelling vascular catheters[1]Strongly consider in non-neutropenic candidaemia; line-related sources are common
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Caspofungin[1] | Echinocandin | 70 mg IV loading then 50 mg IV daily | — | First-line for candidaemia and most invasive candidiasis (covers most Candida spp including C. glabrata; limited CNS penetration) |
| Anidulafungin or micafungin[1] | Echinocandin (alternative) | Anidulafungin 200 mg IV loading then 100 mg daily; micafungin 100 mg IV daily | — | Alternative echinocandins; equivalent efficacy |
| Fluconazole[1] | Triazole | 800 mg IV/PO loading then 400 mg daily; step-down from echinocandin once species susceptible (e.g., C. albicans, C. parapsilosis) | 12 mg/kg loading then 6–12 mg/kg/day | Step-down therapy; primary for non-severe oropharyngeal/oesophageal candidiasis; AVOID for C. krusei, C. glabrata (susceptibility-dose-dependent), C. auris |
| Voriconazole or isavuconazole[1] | Triazole (broader) | Voriconazole 6 mg/kg IV q12h × 2 doses then 4 mg/kg q12h | — | Step-down for fluconazole-resistant Candida (e.g., some C. krusei, C. glabrata) |
| Liposomal amphotericin B[1] | Polyene | 3–5 mg/kg IV daily | 3–5 mg/kg IV daily | Salvage; CNS infection, endocarditis, neonatal candidiasis |
| Fluconazole (vulvovaginal)[1] | Topical / oral triazole | 150 mg PO single dose; recurrent: 150 mg every 72 h × 3 doses then weekly × 6 months | — | Simple uncomplicated VVC; topical clotrimazole or miconazole are alternatives |
Caspofungin[1]
Echinocandin
- Adult
- 70 mg IV loading then 50 mg IV daily
- Paediatric
- —
First-line for candidaemia and most invasive candidiasis (covers most Candida spp including C. glabrata; limited CNS penetration)
Anidulafungin or micafungin[1]
Echinocandin (alternative)
- Adult
- Anidulafungin 200 mg IV loading then 100 mg daily; micafungin 100 mg IV daily
- Paediatric
- —
Alternative echinocandins; equivalent efficacy
Fluconazole[1]
Triazole
- Adult
- 800 mg IV/PO loading then 400 mg daily; step-down from echinocandin once species susceptible (e.g., C. albicans, C. parapsilosis)
- Paediatric
- 12 mg/kg loading then 6–12 mg/kg/day
Step-down therapy; primary for non-severe oropharyngeal/oesophageal candidiasis; AVOID for C. krusei, C. glabrata (susceptibility-dose-dependent), C. auris
Voriconazole or isavuconazole[1]
Triazole (broader)
- Adult
- Voriconazole 6 mg/kg IV q12h × 2 doses then 4 mg/kg q12h
- Paediatric
- —
Step-down for fluconazole-resistant Candida (e.g., some C. krusei, C. glabrata)
Liposomal amphotericin B[1]
Polyene
- Adult
- 3–5 mg/kg IV daily
- Paediatric
- 3–5 mg/kg IV daily
Salvage; CNS infection, endocarditis, neonatal candidiasis
Fluconazole (vulvovaginal)[1]
Topical / oral triazole
- Adult
- 150 mg PO single dose; recurrent: 150 mg every 72 h × 3 doses then weekly × 6 months
- Paediatric
- —
Simple uncomplicated VVC; topical clotrimazole or miconazole are alternatives
Safety-net
- Complete the full course of antifungal even after symptoms resolve — invasive candidiasis recurs rapidly with under-treatment[1]
- Recurrent thrush in mouth or genital area without obvious cause — request HIV testing and look for diabetes[1]
- If candidaemia identified during admission, follow-up dilated eye exam at 1–2 weeks even if no symptoms — endophthalmitis is silent until late[1]
Referral criteria
- Candidaemia with septic shock or end-organ involvementICU and infectious diseases same-day[1]
- Candida endocarditis or endophthalmitisCardiothoracic / ophthalmology and infectious diseases urgent[1]
- C. auris isolationInfection prevention and infectious diseases for isolation, susceptibility testing, and screening of contacts[1]
- Recurrent vulvovaginal candidiasis (≥4 episodes per year)Gynaecology for maintenance therapy and predisposition workup[1]
Clinical summary
Diagnosis and treatment of invasive candidiasis (candidaemia, deep-seated tissue, oesophageal, oropharyngeal, vulvovaginal); echinocandins as first-line for invasive disease.