Summary of Recent Updates too Invasive Candidiasis Guidelines
This article details meaningful shifts in the guidelines for diagnosing and treating invasive candidiasis, reflecting a move towards more targeted approaches and a strong emphasis on antifungal stewardship. Here’s a breakdown of the key changes:
1. Diagnosis:
* Conservative Approach: Globally, guidelines emphasize conventional culture and microscopy as the primary diagnostic methods.
* Biomarkers & Molecular Tests: These are recommended only in validated situations, notably where test reliability is a concern.
* Focus on Reliability: The updates acknowledge varying reliability of newer tests and prioritize established methods.
2. Treatment – A Narrowed Scope for Preventative Antifungals:
* Reduced Empiric use: The broad use of preventative antifungals in ICU patients (as previously recommended in 2016) is now significantly restricted.
* High-Risk Groups Only: empiric or prophylactic treatment is now limited to patients with:
* Severe necrotizing pancreatitis
* Recurrent gastrointestinal perforation
* Hemodynamic instability with additional risk factors
* High-risk intra-abdominal catastrophes
* No Routine Use: Routine empiric therapy for critically ill, non-neutropenic, non-transplant patients is no longer supported.
* European Alignment: European consensus mirrors this reduction,focusing empiric treatment on septic shock,unexplained clinical deterioration,or a high burden of risk factors.
3. Preferred treatments & Stewardship:
* Echinocandins Remain Key: Echinocandins are still the preferred treatment due to thier effectiveness and safety. Rezafungin (once-weekly) offers increased flexibility.
* Liposomal Amphotericin B: An choice when echinocandins aren’t suitable or resistance is present.
* Step-down Therapy: Fluconazole or voriconazole are reserved for stable patients with confirmed susceptibility and source control.
* Antifungal Stewardship is Paramount: Minimizing unnecessary broad-spectrum antifungal use, utilizing diagnostics wisely, and fostering collaboration between specialists are crucial to combat rising resistance and manage costs.
4. Ocular Involvement:
* Continued Screening: Ophthalmologic evaluation is still recommended for all candidemia patients.
* Differing Approaches:
* IDSA & global: Comprehensive screening, especially for symptomatic patients or those with higher risk.
* American Academy of Ophthalmology: Symptom-driven approach, with routine fundoscopy for symptomatic or outpatient-acquired cases, and deferred evaluation for asymptomatic inpatients.
* treatment: Echinocandins are not recommended for ocular involvement.Fluconazole or voriconazole are preferred (if susceptible), with liposomal amphotericin B used for resistance or intolerance. Severe cases may require more invasive interventions.
Driving Forces Behind the Changes:
* 2021 BDG Review: Clarified the limitations of non-culture diagnostics.
* 2025 ECMM/ISHAM/ASM Guideline: Established a global standard for diagnosis, treatment, and stewardship.
In essence, the updated guidelines represent a shift towards a more cautious and targeted approach to managing invasive candidiasis, prioritizing accurate diagnosis, judicious antifungal use, and a strong focus on stewardship to preserve the effectiveness of available treatments.
