Candidaemia in the non-neutropenic patient: A critique of the guidelines

Several guidelines have been published on the management of candidaemia. These guidelines vary in their recommendations, and the lack of consistency between the guidelines has implications for the management of candidaemia. We critiqued five guidelines, including the Infectious Diseases Society of America (IDSA) Guidelines for the Management of Candidiasis, the Canadian Clinical Practice Guidelines for Invasive Candidiasis in Adults, the Joint Recommendations of the German Speaking Mycological Society and the Paul-Ehrlich-Society for Chemotherapy, the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Guideline for the Diagnosis and Management of Candida Diseases, and the Brazilian Guidelines for the Management of Candidiasis. The recommendations in these guidelines vary in all major areas of management, including choice of initial therapy, species-specific therapy (Candida glabrata and Candida parapsilosis), transition to oral therapy (3 days as per IDSA but 10 days as per ESCMID), catheter removal and specialty referrals. We found that too much emphasis has been placed on themes such as predicting the infecting species (and therefore fluconazole susceptibility) or the need for investigations such as echocardiography. We also stress that guidelines fail to provide adequate information (due to lack of evidence) on the most relevant issues that clinicians face when managing candidaemia, such as the place for fluconazole in the treatment of C. glabrata, the clinical relevance of dose-dependent susceptibility to fluconazole, and the timing of step-down therapy.