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IDSA updates guidelines for Candidiasis management
Recommendations for the use of echinocandins and an expanded spectrum of azoles as first-line therapy for the treatment of some forms of candidiasis were key features of the updated clinical practice guidelines published recently by the Infectious Diseases Society of America.
Peter Pappas, MD, of the division of infectious diseases in the department of medicine at the University of Alabama, Birmingham, was a member of the panel who wrote the guidelines. “The main difference between the current guidelines and the previous set has to do with the up-front use of echinocandins for patients with candidemia or suspected invasive candidiasis who have more severe infections and/or who have had prior azole exposure,” he said.
Non-neutropenic adult patients with candidemia should be treated with fluconazole or by an accepted echinocandin. Accepted echinocandin therapies include caspofungin, micafungin or anidulafungin. For patients with moderately severe to severe illness or who have had prior azole therapy, echinocandins are recommended. Patients with milder forms of infection or no prior azole experience may be treated with fluconazole, according to the updated IDSA recommendations.
Echinocandins also have been recommended as first-line therapy for non-neutropenic patients with Candida albicans, Candida glabrata and suspected severe invasive candidiasis. Neutropenic patients with suspected severe candidemia and C. glabrata may also be treated with echinocandins. For patients with Candida parapsilosis, fluconazole, a lipid formulation of amphotericin B deoxycholate or an echinocandin regimen are all appropriate first-line therapies. For patients with Candida krusei, voriconazole, a lipid formulation of amphotericin B deoxycholate or an echinocandin regimen are appropriate.
In most cases, treatment with an azole is also acceptable in less severe forms of infection. When susceptibility data demonstrates that an azole may be effective, transitioning from echinocandin to azole therapy is acceptable, according to the recommendations.
“We often do not have susceptibility data available at the time of diagnosis, so we decided that clinicians should assume a patient is resistant if they are on an azole or have had recent exposure to one,” Pappas said. “Much of what we do is based on prediction because we do not have all the information in real time.”
Other recommendations
Amphotericin B deoxycholate or a lipid formulation of amphotericin B deoxycholate are acceptable alternatives if other antifungal treatments are unavailable or if tolerance is an issue.
Fluconazole also is recommended as first-line therapy for solid-organ transplant recipients, patients in the ICU, patients with chemotherapy-induced neutropenia and stem cell transplant recipients. For solid organ transplant patients, liposomal amphotericin B deoxycholate may be used for prophylaxis after operation. Posaconazole or echinocandin therapy also may be used for stem cell transplant recipients or patients with chemotherapy-induced neutropenia.
Pappas said that more detailed data have emerged in recent years, which allowed the panel to provide multiple options for recommended therapy in many cases. However, he said that the data also gave the panel the opportunity to emphasize certain agents over others. “In this iteration of the guidelines, we exercised our prerogative to take sides where there is data to support one agent instead of another,” he said. “For the first time, we try to make distinctions between agents. The result is a more specific set of guidelines.”
Clin Infect Dis. 2009;48:503-535.