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Appropriate use of antifungal guidelines

This article describes the most-used guidelines for the treatment of candidiasis and highlights various antifungal strategies according to the clinical setting and the availability of new compounds

Matteo Bassetti MD PhD Elda Righi Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy

Novel antifungal drugs have been recently developed for various indications. Almost all of these new compounds are employed for the treatment of candidaemia, which represents a relatively common cause of nosocomial bloodstream infection (BSI).1

The selection of an antifungal

regimen (AR) is based on multiple factors, including patients’ characteristics, hospital setting, strain of Candida and site of infection. The most appropriate AR can be chosen from three main groups of antifungals: the azoles (fluconazole, voriconazole, posaconazole, itraconazole, ravuconazole); the polyenes (amphotericin B deoxycholate, lipid complex, liposomal); and the echinocandins (caspofungin, micafungin, anidulafungin). Although different antifungals can show comparable efficacy in treating candidaemia, their differences in terms of toxicity, drug–drug interactions and selection of resistances remain significant and can affect the clinical outcome of fragile patient populations, such as the critically ill. Thus, specific guidelines have been created in order to direct the clinician in the challenging selection of the optimal AR.2,3


Candida Candida spp represent the fourth most- frequently isolated pathogen in BSI.1 Among patients in the intensive care unit (ICU), crude mortality rates can range from

“Although different antifungals can show comparable efficacy in treating candidaemia, their differences can affect the clinical outcome of fragile patient populations.”

25 to 60%, with an estimated Candida- attributable mortality as high as 47%.4–6 Although risk factors associated to the ICU (for example, use of broad-spectrum antibiotics, intravascular catheters, parenteral nutrition and high Acute Physiology and Chronic Health Evaluation II [APACHE II score]) are frequently present in patients with candidaemia,7

other hospital settings such as the internal medicine wards (IMW) have shown increasingly rates of Candida infections.5,8 In IMW, candidaemia was associated with higher mortality rates compared with other wards (51.1% versus 38.2%, p<0.02) and delayed antifungal treatment (>48 hours after having the first positive blood culture [BC]) with poor outcomes.8

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