Information for Healthcare Professionals about Invasive Candidiasis

Clinical features

Signs and symptoms of invasive candidiasis are often non-specific and include fever and chills that do not respond to antibacterial treatment. Candidemia is the most common form of invasive candidiasis; other forms include endocarditis, peritonitis, meningitis, osteomyelitis, arthritis, and endophthalmitis. Invasive candidiasis is associated with an in-hospital all-cause mortality of approximately 30%.

Candida auris has emerged globally since 2009, including in the United States from mid-2015, and is very concerning because it is highly drug-resistant, causes invasive infections associated with high mortality, and spreads easily between patients in healthcare settings.

Etiologic agent

Candida albicans, C. glabrata, C. parapsilosis, C. tropicalis, and C. krusei are most common. Species distribution varies by patient population and geographic region.

Reservoir

Candida is a commensal organism of the gastrointestinal tract and skin.

Transmission

Most infections arise from the endogenous flora of patients with risk factors following disruption of skin and mucosal barriers. Less commonly, Candida can be transmitted via healthcare workers’ hands or contaminated medical devices.

Diagnosis

Invasive candidiasis is primarily diagnosed with blood culture. Newer culture independent diagnostic methods are promising but are not yet widely used. The Beta-D-glucan assay is approved as an adjunctive diagnostic tool but is not a very specific test for Candida. Determining the species of Candida causing the infection is important to guide appropriate antifungal treatment.

Treatment

For most adult patients with candidemia, an echinocandin is recommended as initial therapy, with transition to fluconazole once the infecting species and antifungal susceptibility are known and blood cultures have cleared. Fluconazole is an acceptable alternative to an echinocandin as initial therapy in selected patients, including those who are not critically ill and who are considered unlikely to have a fluconazole-resistant Candida infection. Alternative treatments include voriconazole and amphotericin B formulations. In general, treatment should continue for two weeks after clearance of Candida from the bloodstream and resolution of symptoms attributable to candidiasis. Intravenous catheter removal is recommended for non-neutropenic patients and can be considered for neutropenic patients. For neonatal candidiasis, the recommended primary treatment is amphotericin B deoxycholate or fluconazole for two weeks after clearance of Candida from the bloodstream and resolution of attributable symptoms.

Treatment recommendations vary for other forms of invasive candidiasis. For detailed treatment guidelines, please refer to the Infectious Diseases Society of America’s Clinical Practice Guidelines for the Management of CandidiasisExternal.

Risk factors

Common risk factors for invasive candidiasis include:

  • Critical illness with a prolonged intensive care unit stay
  • Presence of central venous catheters
  • Use of broad-spectrum antibiotics or total parenteral nutrition
  • Having hematologic or solid organ malignancy, stem cell transplantation, neutropenia, or recent abdominal surgery (especially in the presence of an anastomotic leak)
  • Being a pre-term infant with a very low birth weight
  • Having renal failure or hemodialysis
  • Injection drug use
Prevention

In healthcare settings, these measures are important to prevent invasive candidiasis:

  • Adhering to hand hygiene recommendations
  • Following recommendations for placement and maintenance of central venous catheters
  • Practicing antibiotic stewardship

Some groups of patients may benefit from antifungal prophylaxis:

  • Some solid organ transplant recipients
  • High-risk ICU patients
  • Patients with chemotherapy-induced neutropenia
  • Stem cell transplant recipients with neutropenia
Surveillance and statistics

CDC performs active population-based surveillance for Candida bloodstream infections in certain areas. Click here for more information about surveillance and statistics.

Areas for further research
  • Describe the national burden of candidemia
  • Identify new and emerging risk factors for invasive candidiasis
  • Target areas for intervention and prevention strategies
  • Further develop laboratory methods to more rapidly diagnose Candida infections and detect antifungal resistance
  • Better understand the drivers, mechanisms, and public health burden of antifungal resistant-Candida infections to identify the best prevention methods