American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists · 2026
Clinical controversies in the management of candidemia in adults and children.
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Cluck David B, White Bryan P, Hilzendager Sarah A, Ryder Jonathan H, Tu Patrick J, McPherson Amanda Z, Rogers Daniel J, Chastain Daniel B
Аннотация
PURPOSE: Candidemia remains associated with substantial morbidity and mortality despite advances in antifungal therapy, yet multiple aspects of management remain controversial. This review synthesizes emerging evidence to address unresolved clinical dilemmas in candidemia management.
SUMMARY: This publication reviews data on optimized antifungal dosing, rapid diagnostic tests (RDTs), antifungal susceptibility testing (AFST), echinocandin-to-azole transition, treatment duration, ophthalmologic screening, echocardiographic evaluation, Candida endocarditis, the place in therapy of rezafungin, antifungal resistance, and dosing considerations in children. Substantial pharmacokinetic variability in critically ill and obese patients supports individualized dosing strategies to reduce underexposure. Echinocandin-to-azole transition after 3 to 5 days appears safe in clinically stable patients with bloodstream sterilization and predicted or confirmed azole susceptibility. Although the standard 14-day duration remains a guideline-supported recommendation, emerging evidence suggesting shorter durations may be feasible in carefully selected patients with truly uncomplicated candidemia. Risk-based approaches to ophthalmologic screening and echocardiography may improve diagnostic stewardship while reducing unnecessary testing. Echinocandins appear at least as effective and safer than amphotericin B for Candida endocarditis. Rezafungin offers a practical once-weekly alternative for select patients requiring prolonged intravenous therapy, although evidence for deep-seated infection remains limited. Increasing resistance among non-albicans Candida species, particularly C. parapsilosis, C. glabrata, and C. auris further reinforces the importance of AFST and ongoing surveillance.
CONCLUSION: Optimal candidemia management increasingly depends on individualized antifungal strategies, integration of RDTs and AFST, earlier species-directed therapy transitions, and selective evaluation for metastatic complications. Future studies are needed to better define uncomplicated candidemia, optimize treatment duration, and address evolving antifungal resistance.
SUMMARY: This publication reviews data on optimized antifungal dosing, rapid diagnostic tests (RDTs), antifungal susceptibility testing (AFST), echinocandin-to-azole transition, treatment duration, ophthalmologic screening, echocardiographic evaluation, Candida endocarditis, the place in therapy of rezafungin, antifungal resistance, and dosing considerations in children. Substantial pharmacokinetic variability in critically ill and obese patients supports individualized dosing strategies to reduce underexposure. Echinocandin-to-azole transition after 3 to 5 days appears safe in clinically stable patients with bloodstream sterilization and predicted or confirmed azole susceptibility. Although the standard 14-day duration remains a guideline-supported recommendation, emerging evidence suggesting shorter durations may be feasible in carefully selected patients with truly uncomplicated candidemia. Risk-based approaches to ophthalmologic screening and echocardiography may improve diagnostic stewardship while reducing unnecessary testing. Echinocandins appear at least as effective and safer than amphotericin B for Candida endocarditis. Rezafungin offers a practical once-weekly alternative for select patients requiring prolonged intravenous therapy, although evidence for deep-seated infection remains limited. Increasing resistance among non-albicans Candida species, particularly C. parapsilosis, C. glabrata, and C. auris further reinforces the importance of AFST and ongoing surveillance.
CONCLUSION: Optimal candidemia management increasingly depends on individualized antifungal strategies, integration of RDTs and AFST, earlier species-directed therapy transitions, and selective evaluation for metastatic complications. Future studies are needed to better define uncomplicated candidemia, optimize treatment duration, and address evolving antifungal resistance.