ICU day 8, persistent fever on broad-spectrum antibiotics; central line, TPN, recent abdominal surgery
ABCDE
Resuscitate for sepsis as usual, then treat the fungus as a source-control problem: take blood cultures, remove or exchange the line, and start an echinocandin before speciation.
Risk-stratify → central venous catheter, TPN, broad-spectrum antibiotics, abdominal surgery or perforation, dialysis, steroids, neutropenia, colonisation at multiple sites
Candidaemia → start an echinocandin (caspofungin 70 mg then 50 mg daily) first-line, remove or exchange the central line, and repeat blood cultures every 24–48 h until negative
Eye and heart → dilated ophthalmological examination in symptomatic patients or when clinically indicated; echocardiography if cultures stay positive or a device is in situ
Step down → fluconazole once the patient is stable and the isolate is susceptible; treat for at least 14 days after the first negative culture, longer with metastatic foci
Moulds → invasive aspergillosis — voriconazole or isavuconazole first-line, supported by galactomannan, β-D-glucan and a CT halo sign; mucormycosis — liposomal amphotericin B with urgent surgical debridement and reversal of immunosuppression
Order set
- Blood cultures × 2 (peripheral + line)
- β-D-glucan ± galactomannan
- Remove/exchange central line
- Echinocandin first dose now
- CT chest/sinuses if mould suspected
- Dilated fundoscopy
- Echocardiogram if persistently positive
Criteria
AdmitAny candidaemia — it is never a contaminant
ICUSeptic shock, persistent fungaemia, suspected mucormycosis, or endocarditis
DischargeCompleted course, cultures negative, line removed, eye and echo assessment done
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Positive Candida blood culture
- Periorbital or palatal black eschar
- Neutropenia with a new pulmonary infiltrate
- Persistent fungaemia beyond 72 h of therapy
Differentials
- Bacterial line sepsis
- Undrained intra-abdominal collection
- Drug fever
- Venous thromboembolism
- Tuberculosis in the immunosuppressed
Common mistakes
- Calling a Candida blood culture a contaminant
- Leaving the line in
- Starting fluconazole first in an unstable or azole-exposed patient
- Waiting for speciation before treating
- Treating airway Candida colonisation, which needs no antifungal
Disposition & follow-up
Echinocandin until stable and speciated, then step down; infectious diseases review for every candidaemia; source control decides the outcome more than the drug choice.
Discharge package
MedicationsComplete the full antifungal course
Follow-upInfectious diseases follow-up; repeat imaging for mould disease
LifestyleLine care and glycaemic control
Warning symptomsFever, new visual symptoms, breathlessness, facial pain or black nasal discharge
💊 Treatment detail — doses & preparation
Caspofunginechinocandin
Dose70 mg IV loading, then 50 mg IV daily (35 mg in Child-Pugh B)
PreparationReconstitute and infuse over 1 h
MonitorLFTs; few interactions, no renal adjustment
Fluconazole (step-down)triazole
Dose800 mg (12 mg/kg) loading then 400 mg (6 mg/kg) daily, adjusted for renal function
PreparationIV or oral — bioavailability is near-identical
MonitorQT interval, LFTs, CYP2C9/3A4 interactions
Liposomal amphotericin Bpolyene
Dose5 mg/kg IV daily; 5–10 mg/kg for mucormycosis
PreparationIn 5% glucose, over 30–120 min
MonitorK⁺, Mg²⁺, creatinine, infusion reactions
📖 IDSA Candidiasis 2016 / IDSA Aspergillosis 2016 · ICU chapter 39 · Invasive Fungal DiseaseReviewed September 2026