Invasive candidiasis in critical care setting, updated recommendations from “Invasive Fungal Infections-Clinical Forum”, Iran

Table 1 Recommended treatment options for invasive candidiasis in adult non-neutropenic critically-ill patients based on the current international and local practice guidelines/consensus statements

Guideline	First choice	First alternative	Second alternative
ECCMID[15]	ECH	VCZ, L-AMB	FCZ
European experts opinion[16]	FCZ (stable patients and susceptible isolates) ECH (severe sepsis, micafungin last choice)	L-AmB
IDSA[14]	FCZ (stable patients, azole naive) ECH (critically ill, Severe sepsis, recent azole exposure)	AmB or L-AmB	VCZ
Canadian practice guideline for invasive candidiasis in adults[17]	FCZ (stable patients, azole naïve) ECH (stable or unstable patients, recent azole exposure, avoid in C. parapsilosis)	AmB or L-AmB
Consensus statement from the Iranian panel of experts[12]	FCZ (stable, No prior azole exposure, when hospital epidemiology indicates low incidence of NAC Spp.) ECH (hemodynamic instability, Fluconazole resistance)	VCZ, AmB or L-AmB (if available), considering the tolerability and cost vs utility

ECCMID: European Congress of Clinical Microbiology and Infectious Diseases; ECH: Echinocandins; VCZ: Voriconazole; AmB: Amphotericin B; L-AmB: Liposomal Amphotericin B; FCZ: Fluconazole; IDSA: Infectious Disease Society of America; NAC: Non-albicans Candida.

Table 2 Recommended therapy with proper dosing in invasive candidiasis based on the current practice guidelines and consensus statements[12,14-16]

Recommended treatment	Candidemia(non-neutropenic patients, moderate to severe illness)	Candidemia(neutropenic patients)	Candidaglabrata	Candida parapsilosis	Solid organ transplant recipients (prophylaxis)	ICU prophylaxis(high risk patients only)
Caspofungin	70 mg iv loading dose, then 50 mg/d per iv	70 mg iv loading dose, then 50 mg/d per iv	70 mg iv loading dose, then 50 mg/d per iv
Micafungin	100 mg/d per iv	100 mg/d per iv	100 mg/d per iv
Anidulafungin	200 mg/iv loading dose; then 100 mg/d per iv	200 mg/iv loading dose; then 100 mg/d per iv	200 mg/iv loading dose; then 100 mg/d per iv
Fluconazole				800 mg iv loading, then 400 mg/d per iv or PO	200-400 mg/d iv or PO for 7-14 d	400 mg/d per iv or PO
(Alternative regimen) Fluconazole	800 mg iv loading, then 400 mg/d per iv or PO	800 mg iv loading, then 400 mg/d per iv or PO
(Alternative regimen) Voriconazole if mold coverage is desired		6 mg/kg per iv q12h for 2 doses; then 4 mg/kg iv q12h or 200 mg PO q12h
(Alternative regimen) Fluconazole or Voriconazole			With susceptibility testing
(Alternative regimen) Echinocandins				If already responding to therapy
(Alternative regimen) Liposomal Amphotericin B					1-2 mg/kg iv/d for 7-14 d

ICU: Intensive care unit; PO: Per Os (Oral administration); iv: Intravenous.