Controversies in Candida management

Invasive candidiasis (IC) is associated with increased morbidity and mortality. Although advances in diagnosis and management of this infection have been reached, there remain several controversies. The aim of this review is to tackle some of these controversies and shed light on studies that support the different sides of the arguments. Regarding central line-associated candidaemia, the current evidence appears to be more in favour of early central line removal whenever possible. Otherwise, antifungal agents such as echinocandins or polyenes should be the preferred agents. In the setting of infection with Candida parapsilosis and in light of the high minimum inhibitory concentrations (MICs) to echinocandins, azoles have been considered the preferred treatment agents. However, a recent study appears to indicate that empirical echinocandin use was not associated with a worse outcome when the isolated species was C. parapsilosis. Different strategies of antifungal treatment have been considered, namely prophylactic, empirical, pre-emptive or directed therapies. Whilst there is consensus on the need for prophylaxis in high-risk cancer patients, especially haematological malignancy and stem cell transplant populations, it remains debatable whether prophylaxis is of benefit in very low birthweight infants and in intensive care unit (ICU) patients. In the era of antifungal resistance and where antifungal stewardship has been advocated, pre-emptive therapy based on predictive models with various Candida risk scores and sensitive non-culture-based biomarkers such as β-d-glucan appears to be a more cost-effective approach. Future efforts should be directed to optimise clinical predictive models and reliable biomarkers for early detection of IC.