Antifungal resistance: the clinical front

The emergence of resistance and changes in the spectrum of Candida infections have led to an increased interest in susceptibility testing of antifungal drugs. Such testing may be particularly useful in patients with invasive candidiasis who have been previously treated with azole antifungals, those whose infections are not responding to treatment, and those with infections caused by non-albicans species of Candida. The choice of a specific antifungal depends on the clinical status of the patient, the relative toxicity and efficacy of the drug in the given patient population, the infecting species and antifungal susceptibility of the isolate, and the patient's prior exposure to antifungal agents. Infectious Diseases Society of America recommendations for the initial management of candidemia and acute disseminated candidiasis include an azole, caspofungin, amphotericin B (AmB), or a combination of fluconazole plus AmB. Caspofungin and voriconazole show good activity against most Candida species and may be good alternatives for patients with Candida glabrata and Candida krusei infections and for those with relapsing infections.