Critical Care - Management of Candidaemia
- Involves all critical care areas including OCC/CICU/Neuro-ICU/CTCCU wards.
- Applicable only to fungal infections caused by the Candida species.
- For fungal infections caused by other species - contact Micro/ID.
- For management of invasive candida outside critical care see invasive candida guideline
Treatment of confirmed Candidaemia
- Positive blood culture with Candida species isolation
- Discuss all cases with Micro/ID
- Recommend ophthalmology consult to obtain a dilated eye exam within the first week after diagnosis of candidemia
- Recommend early removal of central venous catheters (CVCs) if the CVC is the presumed source, if possible
Treat for 14 days from the date of the last positive blood culture.
Preferred
Caspofungin iv OD (see dosing table below). Review daily with Micro/ID.
| Caspofungin IV dose | |
| Body weight up to 80kg |
Loading dose: 70mg iv OD for day one Maintenance dose: 50mg iv OD |
| Body weight 80kg or more |
Loading dose: 70mg iv OD for day one Maintenance dose: 70mg iv OD |
|
Concurrent use of enzyme inducers* (regardless of weight) |
Loading dose: 70mg iv OD for day one Maintenance dose: 70mg iv OD |
|
Moderate hepatic impairment (Child-Pugh score 7 to 9) (regardless of weight) |
Loading dose: 70mg iv OD for day one Maintenance dose: 35mg iv OD |
*Phenytoin, carbamazepine, dexamethasone or rifampicin. This list is not exhaustive, check BNF and SPC for interactions.
Alternative
Discuss cases with Micro/ID. Who may recommend:
fluconazole 800mg iv/po once only on day 1 followed by:
- 400mg iv/po od for Candida albicans.
- 800mg iv/po od for non-albicans Candida.
OR
amphotericin B liposomal (Tillomed/Gilead/AmBisome) 3-5mg/kg iv od
Switch to fluconazole, oral preferred (doses stated above) in the following circumstances;
- Clinically stable patient,
- Candida species that are susceptible to fluconazole,
- Negative repeat blood cultures following initiation of antifungal therapy (usually 5-7 days)
Prophylaxis of Candida infection in ICU
Antifungal agents are not generally advised for prophylaxis in ICU unless the patient has significant immunocompromise, such as solid organ tranplantation, BMT or haemato-oncology.
Pre-emptive therapy for Candida infection
Consider pre-emptive therapy if risk factors for invasive candidiasis are present and the patient has worsening sepsis syndrome despite broad spectrum antibiotics after 3-4 days.
Risk factors include:
- Broad Spectrum Antibiotics
- CVC in situ
- TPN
- Haemofiltration
- Major Surgery
- Pancreatitis
- Steroids or other immunosuppressive drugs
- Ventilation
- Candida colonisation at 2 or more sites
Treat for 7 days.
Preferred Therapy
fluconazole 800mg iv/po once only on day 1 followed by 400mg iv/po od
Should Candida subsequently be isolated from blood cultures, follow guideline as for confirmed Candidaemia (see above)