Echinocandin-first candidaemia bundle, C. auris precautions, voriconazole for aspergillosis and urgent liposomal amphotericin plus surgery for mucormycosis.
At the bedside
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Candidaemia bundle
Echinocandin first line; remove/replace CVC; repeat blood cultures daily until negative; dilated fundoscopy (in neutropenia after recovery); echocardiography if persistent; 14 days after first negative culture and symptom resolution.
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Step-down
Switch to fluconazole after 5-7 days if isolate susceptible, patient stable and repeat cultures negative.
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Candida auris
Fluconazole-resistant, spreads in ICUs: echinocandin, contact precautions, single room, chlorine/peracetic-acid environmental cleaning, inform infection control.
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Do not treat candiduria or respiratory Candida
Usually colonisation; treat candiduria only in neutropenia, urological procedures or symptomatic infection.
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Aspergillosis
CT chest, serum/BAL galactomannan; voriconazole 6 mg/kg q12h × 2 then 4 mg/kg q12h (TDM); isavuconazole or L-AmB alternatives.
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Mucormycosis
Emergency: L-AmB 5 mg/kg/day (10 mg/kg CNS), urgent surgical debridement (ENT/maxillofacial/neurosurgery), control glucose and acidosis, reduce steroids/immunosuppression; step-down posaconazole/isavuconazole.
Candidaemia first line
Caspofungin (or micafungin/anidulafungin)
- Dose
- 70 mg load, then 50 mg daily
Micafungin 100 mg daily needs no load.
Step-down for susceptible Candida
Fluconazole
- Dose
- 800 mg load, then 400 mg daily
- Worked example
- 70 kg: 12 mg/kg ≈ 800 mg, then 6 mg/kg ≈ 400 mg
Invasive aspergillosis
Voriconazole
- Dose
- 6 mg/kg q12h × 2, then 4 mg/kg q12h
- Target
- Trough 1-5.5 mg/L
- Worked example
- 70 kg: 420 mg × 2, then 280 mg q12h; trough day 5
Mucormycosis
Liposomal amphotericin B
- Dose
- 5 mg/kg/day (10 mg/kg/day for CNS involvement)
- Preparation
- Reconstitute 50 mg vials; dilute in 5% dextrose (not saline) to 0.2-2 mg/mL over 2 h
- Worked example
- 70 kg: 350 mg/day (7 vials)
References
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Candida in blood culture
Step 1 of ~6
Start echinocandin; remove CVC
Based on Pappas PG, Kauffman CA, Andes DR, et al. Educational use; follow local protocol.
Pathophysiology
Candida gains access from colonised gut or skin through CVCs, abdominal surgery and broad-spectrum antibiotics. Moulds are inhaled; angioinvasion causes infarction and necrosis, especially in mucormycosis where acidosis and high iron availability (DKA) drive growth.
Evidence
- IDSA 2016 candidiasis guideline [Pappas 2016]. IDSA 2016 aspergillosis guideline [Patterson 2016]. ECMM/MSG 2019 global mucormycosis guideline [Cornely 2019].
Controversies
- Empirical antifungals in non-neutropenic ICU patients (EMPIRICUS showed no benefit); antifungal prophylaxis in high-risk surgical patients.
🇮🇳 India notes
- India has high rates of C. auris and C. tropicalis candidaemia; national guidelines recommend echinocandins first line.
- India had the world's largest COVID-19-associated mucormycosis outbreak (2021); uncontrolled diabetes and steroid overuse remain key risk factors.
- Generic L-AmB is available but expensive; conventional amphotericin is cheaper but more nephrotoxic.
References
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Test yourself
Module quiz · score 70% to complete the module
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.