Summary: Global guideline for the diagnosis and management of candidiasis: an initiative of the ECMM in cooperation with ISHAM and ASM

Introduction

Candida species are the predominant cause of fungal infections in patients treated in hospital settings, causing significant morbidity and mortality worldwide. This clinical practice guide summarises evidence-based recommendations from the European Confederation for Medical Mycology (ECMM) global guideline initiative, developed in cooperation with the International Society of Human and Animal Mycology (ISHAM) and the American Society for Microbiology (ASM).

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Epidemiology and Risk Factors

Type of Candidiasis	Epidemiology	Key Risk Factors
Invasive Candidiasis	Estimated 1,565,000+ cases annually Candidemia is most common presentation More than 85% of fungemia cases in Europe/USA	Immunosuppression Critical illness Indwelling vascular catheters Abdominal surgery Prolonged ICU stay Broad-spectrum antibiotics Total parenteral nutrition
Mucocutaneous Candidiasis	Vulvovaginal candidiasis affects 75% of women at least once Oropharyngeal candidiasis affects up to 20% of advanced HIV patients	HIV/AIDS Diabetes mellitus Poor oral hygiene/dentures Recent antibiotic therapy Pregnancy IL-17 inhibitor therapy
Emerging Threats	Increasing antifungal resistance Healthcare-associated transmission	C. auris outbreaks Fluconazole-resistant C. parapsilosis Healthcare environment exposure

 

Diagnostic Approach

Diagnostic Method	Recommendation Level	Key Points
Clinical Diagnosis	Strongly recommended	Detailed patient history and physical examination Focus on potentially affected organ systems Imaging for suspected disseminated disease
Blood Cultures	Strongly recommended	2-3 blood culture sets (20 mL each) Daily cultures until clearance documented Limited sensitivity (≤50% in deep-seated infection)
Direct Microscopy	Strongly recommended	Apply with optical brighteners Use with cultures for tissue/fluid samples
Species Identification	Strongly recommended	MALDI-TOF mass spectrometry preferred Chromogenic media for mixed infections Sequencing when other methods fail
Biomarkers	Moderately recommended	Serum β-D-glucan (BDG) for presumptive diagnosis Mannan/anti-mannan antibody assays Don't base treatment solely on biomarkers
Molecular Tests	Moderately recommended	Limited range of species detection Use commercial assays over in-house methods Helpful when combined with biomarkers
Susceptibility Testing	Strongly recommended	EUCAST or CLSI methods Required for invasive infections Important for non-responsive mucocutaneous cases

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Treatment of Candidemia and Invasive Candidiasis

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Candidemia without Organ Involvement

Therapy Type	Agents and Dosing	Recomm. Level	Comments
First-line Treatment	Anidulafungin: 200 mg day 1, then 100 mg daily Caspofungin: 70 mg day 1, then 50 mg daily Micafungin: 100 mg daily Rezafungin: 400 mg week 1, then 200 mg weekly	Strong	Broad activity including against C. auris Favourable safety profile Limited drug interactions
Alternative Options	Liposomal amphotericin B: 3 mg/kg dailyFluconazole: 400-800 mg dailyVoriconazole: 6 mg/kg BID day 1, then 4 mg/kg BID	Moderate	For fluconazole: only if the isolate is susceptible Consider local resistance patterns Higher toxicity with amphotericin formulations
Source Control	Central venous catheter removal	Strong	Remove as early as possible (<48-72h) If not feasible, change catheter over guidewire
Step-down Therapy	Fluconazole 400-800 mg daily	Moderate	After 5+ days of echinocandin Patient stable with negative cultures Non-neutropenicSource controlledSusceptible isolate
Duration	14 days after first negative blood culture	Strong	Perform daily blood cultures If positive on day 5, search for persistent source

 

CNS Candidiasis

Therapy Type	Agents and Dosing	Recomm. Level	Comments
First-line Treatment	Liposomal amphotericin B: 3-5 mg/kg daily ± flucytosine 150 mg/kg daily	Strong	Good CNS penetration Synergistic combination
Alternative	Fluconazole: 800 mg BID ± flucytosine	Moderate	For step-down or consolidation Only for susceptible isolates
Surgical Management	Abscess drainage Device removalVentricular drainage	Strong	Critical for source control Manage increased intracranial pressure
Duration	Until clinical and CSF abnormalities resolve	Strong	Individualise based on response Often several months

 

Candida Endocarditis

Therapy Type	Agents and Dosing	Recomm. Level	Comments
Medical Therapy	Liposomal amphotericin B: 3-5 mg/kg daily ± flucytosine OR echinocandin (standard dose)	Strong	Can consider combination therapy
Surgical Management	Valve replacement/repair Device removal	Strong	Within the first week of diagnosis Essential for the cure
Duration	Minimum 6 weeks after surgery	Strong	Longer if complications present Lifelong suppression if unable to remove hardware

 

Ocular Candidiasis

Type	Treatment	Duration	Comments
Endophthalmitis	Fluconazole: 400-800 mg dailyVoriconazole: standard doseLiposomal amphotericin B: 3-5 mg/kg dailyConsider intravitreal amphotericin B	4-6 weeks	Consider early vitrectomy Poor echinocandin penetration
Chorioretinitis with symptoms	Fluconazole or voriconazole	4-6 weeks	For macular involvement Monitor with serial fundoscopy
Chorioretinitis without symptoms	Fluconazole or voriconazole	2 weeks	If candidemia has resolved No evidence of other deep sites

 

Prophylaxis Recommendations

Patient Population	Agent and Dosing	Recomm. Level	Duration
Abdominal Surgery	Fluconazole: 12 mg/kg loading, then 6 mg/kg daily	Moderate	For recurrent GI perforations For anastomotic leakages
Neutropenia/ AML	Posaconazole or other mould-active agents	Strong	During prolonged neutropenia (≥7 days) For induction chemotherapy
Allogeneic HSCT	Fluconazole: standard dose	Strong	From conditioning through engraftment Extended to day 75 post-HSCT

 

C. auris Infection Prevention and Control

Measure	Recomm	Implementation
Screening	Strong	High-risk patients on admission Close contacts of colonised/ infected patients Composite swabs of the axilla and groin
Isolation	Strong	Single room when possible Cohort if necessary
Environmental Cleaning	Strong	Sporicidal disinfectants Hydrogen peroxide, peracetic acid, or chlorine-based Avoid quaternary ammonium compounds
Surveillance	Strong	Monitor for outbreaks Consider genomic typing
Deisolation	Moderate	After 3 negative screens (≥24h apart)

 

General Management Principles

Principle	Recomm. Level	Key Points
Specialist Consultation	Strong	Infectious diseases or clinical microbiology Improves guideline adherence and outcomes
Antifungal Stewardship	Strong	Essential component of antimicrobial stewardship Optimise antifungal use Consider local epidemiology and resistance
Therapeutic Drug Monitoring	Moderate	For triazoles and certain populations Target trough >1 mg/L for echinocandins Use in treatment failure cases
Source Control	Strong	Catheter removal in candidemia Drain abscesses Remove infected prosthetic material when possible

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Summary of Treatment Approach

1. Use echinocandins as first-line therapy for candidemia and most invasive candidiasis.
2. Remove vascular catheters when possible in candidemia
3. Perform daily blood cultures until clearance
4. Consider step-down to oral fluconazole when appropriate
5. Tailor therapy based on species identification and susceptibility
6. Implement rigorous infection control for C. auris
7. Consider local epidemiology when selecting empiric therapy
8. Consult infectious diseases specialists to optimise management