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Infectious Disease · IDSA

Invasive candidiasis

IDSA
A
Source:IDSA 2016 Clinical Practice Guideline for the Management of Candidiasis
Verified Apr 2026
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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

DrugClassAdultPaediatricNotes
Caspofungin[1]Echinocandin70 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]Triazole800 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/dayStep-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]Polyene3–5 mg/kg IV daily3–5 mg/kg IV dailySalvage; CNS infection, endocarditis, neonatal candidiasis
Fluconazole (vulvovaginal)[1]Topical / oral triazole150 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

  1. Complete the full course of antifungal even after symptoms resolve — invasive candidiasis recurs rapidly with under-treatment[1]
  2. Recurrent thrush in mouth or genital area without obvious cause — request HIV testing and look for diabetes[1]
  3. 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.

References

  1. 1.IDSA 2016 Clinical Practice Guideline for the Management of Candidiasis (2016)

On this page

  • Red flags
  • First-line treatment
  • Safety-net
  • Referral
  • References