Candida endocarditis: current perspectives on diagnosis and therapy

Candida infective endocarditis (CIE) is a rare but potentially devastating condition. Although it accounts for only 1-1.5% of infective endocarditis cases, CIE carries a high mortality rate (36-49%) and a substantial risk of relapse. Despite advances in diagnostic and therapeutic strategies, significant uncertainties persist regarding the role and selection of imaging modalities and the most effective medical and surgical management. Furthermore, the best follow-up strategy to promptly detect recurrences in patients with a confirmed diagnosis remains inadequately defined.

This review explores the diagnosis and management of CIE with a particular focus on: (a) optimal use of cardiac imaging studies; (b) challenges associated with antifungal therapy; (c) the limitations and real-world impact of surgical intervention; and (d) strategies for long-term follow-up.

A comprehensive literature search was conducted in PubMed using the terms Candida endocarditis, fungal biomarkers, echocardiography, antifungal therapy, and surgical management. Additional studies were identified through reference screening. Only clinically relevant articles, as judged by the authors, were included.

Diagnosis remains difficult due to intermittently negative blood cultures and limitations of standard endocarditis criteria. Echocardiography is the primary diagnostic modality for patients with candidaemia, and risk stratification to guide its use remains exploratory. Novel diagnostic methods, including fungal biomarkers (1,3-β-D-glucan), molecular assays, and positron emission tomography/computed tomography, may improve detection, but robust clinical data are lacking. Management requires a multimodal approach, combining prolonged antifungal therapy and, when feasible, surgical intervention. Echinocandins or liposomal amphotericin B plus flucytosine are first-line treatments, with fluconazole as a step-down option. Prosthetic valve infections often require lifelong suppressive therapy due to high relapse rates.

Given the high mortality and recurrence rates, early multidisciplinary involvement is crucial. With emerging antifungal resistance, antibiofilm strategies and next-generation antifungals are needed to improve outcomes.