Version June 2024
| Condition or treatment group | Therapy | ||
| Primary | Step-down | Comments | |
| Candidemia | |||
| Nonneutropenic adults | One of the following echinocandins (caspofungin 70 mg IV loading dose, then 50 mg IV daily; micafungin 100 mg IV daily; anidulafungin 200 mg IV loading dose, then 100 mg IV daily) is recommended as initial therapy. An alternative for patients who are not critically ill and who are considered unlikely to have fluconazole-resistant Candida spp* is fluconazole 800 mg (12 mg/kg) oral loading dose, then 400 mg (6 mg/kg) orally¶ daily. A lipid formulation of amphotericin B (3 to 5 mg/kg IV daily) is an alternative if there is intolerance, limited availability, or resistance to other antifungal agents. | For patients who are clinically stable, have isolates that are susceptible to fluconazole, and have negative repeat blood cultures following initiation of antifungal therapy, transition from an echinocandin or lipid formulation amphotericin B to fluconazole is appropriate (usually within five to seven days). For C. glabrata infection, transition to higher-dose fluconazole 800 mg (12 mg/kg) orally daily or voriconazoleΔ 200 to 300 mg (3 to 4 mg/kg) orally twice daily should only be considered for patients with fluconazole-susceptible or voriconazole-susceptible isolates. For infection due to an azole-resistant organism, rezafungin may be considered because of its once-weekly dosing. | When the source is presumed to be the CVC, remove it as early as possible. For candidemia without obvious metastatic complications, treat for 14 days after first negative blood culture result and resolution of signs and symptoms associated with candidemia. Dilated funduscopic examination within a week of diagnosis is recommended for all patients. |
| Neutropenic patients | One of the following echinocandins (caspofungin 70 mg IV loading dose, then 50 mg IV daily; micafungin 100 mg IV daily; anidulafungin 200 mg IV loading dose, then 100 mg IV daily) is recommended as initial therapy. A lipid formulation of amphotericin B (3 to 5 mg/kg IV daily) is a less attractive alternative because of the potential for toxicity. For patients who are not critically ill and who have had no prior azole exposure, an alternative is fluconazole 800 mg (12 mg/kg) oral loading dose, then 400 mg (6 mg/kg) orally¶ daily. In situations in which additional mold coverage is desired, voriconazoleΔ 400 mg orally (or 6 mg/kg IV) twice daily for two doses then 200 to 300 mg orally (or 3 to 4 mg/kg IV) twice daily can be used. | Fluconazole 400 mg (6 mg/kg) orally¶ daily can be used for step-down therapy during persistent neutropenia in clinically stable patients who have fluconazole-susceptible isolates and documented bloodstream clearance. VoriconazoleΔ 200 to 300 mg (3 to 4 mg/kg) orally twice daily can be used as step-down therapy during neutropenia in clinically stable patients who have voriconazole-susceptible isolates and documented bloodstream clearance. | For candidemia without obvious metastatic complications, recommended minimum duration of therapy is 14 days after documented clearance of Candida from the bloodstream, provided neutropenia and signs and symptoms attributable to candidemia have resolved. Dilated funduscopic examination is recommended for all patients; examination should be repeated within 7 days after recovery from neutropenia. CVC removal should be considered on a case-by-case basis. G-CSF-mobilized granulocyte transfusions can be considered in cases of persistent candidemia with anticipated protracted neutropenia. |
IV: intravenous; CVC: central venous catheter; G-CSF: granulocyte colony-stimulating factor.
* Fluconazole should be considered a first-line option only in patients who are stable, have no previous exposure to azoles, and are not at high risk for C. glabrata infection (eg, older adults, underlying malignancy, diabetic); refer to accompanying text.
¶ Since fluconazole is highly bioavailable, oral therapy is appropriate for most patients. IV therapy (at the same dose) should be given to patients who are unable to take oral medications, who are not expected to have good gastrointestinal absorption, or who are severely ill.
Δ Therapeutic drug monitoring should be considered due to widely variable pharmacokinetics; refer to the UpToDate topic review on pharmacology of azoles for details.آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
