General recommendations for the treatment of invasive candidiasis in children*

Condition or treatment group	Treatment
Condition or treatment group	Primary	Alternative	Duration
Candidemia
Nonneutropenic	Echinocandin or LAmB^¶	Fluconazole^Δ or voriconazole^◊	14 days after first negative blood culture and resolution of signs and symptoms.
Neutropenic	Echinocandin or LAmB^¶	Fluconazole^Δ or voriconazole^◊	14 days after first negative blood culture and resolution of signs and symptoms and neutrophil count recovery.
Suspected candidiasis
Nonneutropenic	Echinocandin or LAmB^¶	Fluconazole^Δ	Stop after four to five days in patients with no clinical response who lack supporting evidence for fungal infection. For patients with a clinical response, continuation for two weeks may be warranted.
Neutropenic	Echinocandin or LAmB^¶	Fluconazole^Δ	Until resolution of neutropenia in the absence of documented invasive candidiasis.
Suppurative thrombophlebitis
	Echinocandin or LAmB^¶ or fluconazole^Δ	–	At least two weeks after candidemia cleared and signs/symptoms resolve. Catheter removal and resection of vein recommended.
Endocarditis
	LAmB^¶±flucytosine or high-dose echinocandin	Fluconazole^Δ or voriconazole^◊^§ or posaconazole^§	At least six weeks (valve replacement surgery recommended); chronic suppressive therapy with fluconazole for prosthetic valves.^[1]
Central nervous system candidiasis^¥
	LAmB^¶±flucytosine	Fluconazole^Δ	Usually several weeks, until all signs and symptom and CSF and radiological abnormalities have resolved.
Candida ocular infections^¥
	Fluconazole^Δ or voriconazole^◊ or LAmB^¶±flucytosine	–	At least four to six weeks depending upon resolution of lesions.
Intra-abdominal candidiasis
	Echinocandin or LAmB^¶	Fluconazole^Δ or voriconazole^◊	Determined by adequate source control and clinical response.
Hepatosplenic candidiasis
	Echinocandin or LAmB^¶, followed by fluconazole^Δ	–	Usually months, until lesions have resolved on repeat imaging and neutrophil count recovery.
Candida pyelonephritis^¥^‡
	LAmB^¶ or fluconazole^Δ	LAmB^¶ or fluconazole^Δ	Two weeks; for patients who have nephrostomy tubes or stents in place, removal or replacement may be warranted (if feasible).

LAmB: lipid formulation of amphotericin B; CSF: cerebrospinal fluid.
* Treatment of candidiasis in neonates is discussed separately. Refer to UpToDate content on treatment of Candida infection in neonates.
¶ Toxicity may limit its use.
Δ For patients who are not critically ill and not likely to have fluconazole-resistant isolates (eg, no past exposure to fluconazole).
◊ Generally used as step-down therapy in patients with invasive infection due to Candida krusei and fluconazole-resistant, voriconazole-susceptible Candida glabrata.
§ Data are lacking in children for this indication.
¥ Echinocandins are not recommended for candidiasis involving the eye, central nervous system, or urinary tract because they have relatively poor penetration at these sites.
‡ Voriconazole is not recommended for patients with urinary candidiasis because the active form is minimally excreted in the urine.

Reference:

Baltimore RS, Gewitz M, Baddour LM, et al. Infective Endocarditis in Childhood: 2015 Update: A Scientific Statement From the American Heart Association. Circulation 2015; 132:1487.

Adapted from: Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1.

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General recommendations for the treatment of invasive candidiasis in children*