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id.candidemia.core.v1PRODUCTION
id.candidemia.core.v1

Candidemia / invasive candidiasis

infectious_diseaseacuteadult
Hard-required inputs
0 / 8
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm bloodstream / deep-tissue Candida disease scope (IDSA 2024)

Inputs
0
Actions
0
Advance rule
Set
Advance when

scope confirmed

Patient inputs (12)

Ophtho exam within 1 week of diagnosis (IDSA 2016) and repeat at 2 weeks

Removal of non-tunneled CVC is a Class A IDSA recommendation

Major risk factor; informs species probability (IDSA 2024)

Neutropenic phenotype favors echinocandin + lipid amphotericin and aggressive imaging for hepatosplenic candidiasis (IDSA 2024)

Persistent fever despite broad antibiotics is a sentinel sign (IDSA 2024)

Diagnostic anchor; also drives line-removal timing (IDSA 2024)

Septic shock from candidemia mortality 40-60% — drives ICU disposition (IDSA 2024)

Echinocandin renal-safe; fluconazole / lipid AmB renal dosing/toxicity (IDSA 2024)

TEE if persistent candidemia >5d, valvular disease, prosthetic valve, or embolic phenomena (IDSA 2024)

Lipid emulsions support C. parapsilosis; high-risk population (IDSA 2024)

Adjunct when culture negative; supports invasive candidiasis without candidemia (IDSA 2024)

Azole hepatotoxicity monitoring (IDSA 2024)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningseptic_shock_with_candidemia
    Hypotension on adequate fluids + lactate >2 + Candida bloodstream infection (IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecvc_in_situ_after_48h_of_positive_culture
    Non-tunneled central venous catheter still in place 48 h after first positive Candida blood culture (IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepersistent_candidemia_5_days
    Blood cultures still positive 5 days after appropriate echinocandin + line management (IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereneutropenic_phenotype
    ANC <500 + candidemia (IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverec_auris_isolated
    Candida auris on culture (high MDR risk) (IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereophthalmic_endophthalmitis
    Chorioretinitis or endophthalmitis on dilated fundus exam (IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Candidemia / invasive candidiasis — echinocandin-first per IDSA 2016
axis: candidemia_initial_treatment
Selected axis "Candidemia / invasive candidiasis — echinocandin-first per IDSA 2016" by default fallback (first axis)
  • caspofungin
    first line
    echinocandin
    70 mg IV load × 1 then 50 mg IV daily • IV • daily
    triggers: candidemia_confirmed, invasive_candidiasis_suspected, septic_shock
    IDSA 2016 strong — first-line for non-neutropenic and neutropenic adults; covers most species including azole-resistant C. glabrata and C. krusei
    rxcui 140108
  • micafungin
    first line
    echinocandin
    100 mg IV daily • IV • daily
    triggers: candidemia_confirmed
    IDSA 2016 alternative echinocandin — equivalent efficacy
    rxcui 325887
  • anidulafungin
    first line
    echinocandin
    200 mg IV load × 1 then 100 mg IV daily • IV • daily
    triggers: candidemia_confirmed
    IDSA 2016 alternative echinocandin
    rxcui 341018
  • fluconazole
    second line
    azole
    800 mg (12 mg/kg) IV/PO load × 1 then 400 mg (6 mg/kg) daily • IV/PO • daily
    triggers: stable_patient, C_albicans_or_fluconazole_susceptible, step_down_after_echinocandin
    IDSA 2016 — step-down once stable + susceptible isolate identified; PO has full bioavailability
    rxcui 4450
  • liposomal_amphotericin_B
    rescue
    polyene
    3-5 mg/kg IV daily • IV • daily
    triggers: azole_intolerant, CNS_or_endocarditis_or_endophthalmitis, C_auris_concern
    IDSA 2016 — for refractory disease, deep-seated infection, or pregnancy; nephrotoxicity monitoring
    rxcui 236594
  • voriconazole
    add on
    azole
    6 mg/kg IV q12h × 2 then 3-4 mg/kg q12h • IV/PO • q12h
    triggers: CNS_invasive_candidiasis, eye_involvement
    IDSA 2016 — additional CNS / ocular penetration option
    rxcui 121243

outpatient playbook — drug actions (4)

  1. 1. OPAT echinocandin (continuation)
    Caspofungin 50 mg IV daily OR micafungin 100 mg IV daily OR anidulafungin 100 mg IV daily • IV (peripheral or PICC; OPAT setting) • daily
    trigger: Patient stable + clinically improving + OPAT-eligible + species/susceptibility allows continued echinocandin + completing total duration ≥14 d after first negative blood culture
    IDSA 2016 Pappas — echinocandin first-line; OPAT delivery proven safe (Norris IDSA OPAT 2018) for daily-dosed echinocandins
  2. 2. PO fluconazole step-down (continuation)
    rxcui 4450
    400 mg (6 mg/kg) PO daily; 800 mg (12 mg/kg) load × 1 if not previously loaded • PO • daily
    trigger: Stable + species ID confirms fluconazole-susceptible (C. albicans, C. parapsilosis, C. tropicalis; OR C. glabrata MIC ≤ 32) + ≥ 5-7 d echinocandin + sterile blood cultures + clinical improvement + no endocarditis / endophthalmitis / CNS disease
    IDSA 2016 Pappas — step-down enables PO completion; full PO bioavailability avoids line for completion
  3. 3. OPAT L-AmB (continuation for endocarditis / endophthalmitis / CNS)
    rxcui 236594
    3-5 mg/kg IV daily • IV • daily
    trigger: Endocarditis (6 wk total post-valve-replacement) OR endophthalmitis (4-6 wk minimum after stable funduscopy) OR CNS disease — completing prolonged course at home
    IDSA 2016 Pappas — L-AmB for deep-seated disease; OPAT delivery with creatinine + K + Mg monitoring
  4. 4. rezafungin once-weekly (alternative OPAT continuation)
    200 mg IV q week (after 400 mg load in-hospital) • IV • weekly
    trigger: Patient stable + completing total duration + once-weekly OPAT preferred (REVIVE 2023 alternative)
    Thompson Lancet 2023 (REVIVE) — non-inferior to caspofungin; reduces OPAT visit frequency to weekly (RxCUI not yet captured — flagged in dossier notes)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Blood culture growing yeast (IDSA 2024); Beta-D-glucan elevated in high-risk patient (IDSA 2024); Persistent fever on broad-spectrum antibiotics (IDSA 2024).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Candidemia / invasive candidiasis** (id.candidemia.core.v1).
Phenotype framing: Distinguish C. albicans / glabrata (echinocandin) / parapsilosis (fluconazole-favoured) / krusei (azole-resistant) / auris (multidrug-resistant — isolation) (IDSA 2024)
Scope: Confirm bloodstream / deep-tissue Candida disease scope (IDSA 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Candidemia / invasive candidiasis — echinocandin-first per IDSA 2016**.
1. caspofungin 70 mg IV load × 1 then 50 mg IV daily IV daily (echinocandin, first line) — IDSA 2016 strong — first-line for non-neutropenic and neutropenic adults; covers most species including azole-resistant C. glabrata and C. krusei
2. micafungin 100 mg IV daily IV daily (echinocandin, first line) — IDSA 2016 alternative echinocandin — equivalent efficacy
3. anidulafungin 200 mg IV load × 1 then 100 mg IV daily IV daily (echinocandin, first line) — IDSA 2016 alternative echinocandin
4. fluconazole 800 mg (12 mg/kg) IV/PO load × 1 then 400 mg (6 mg/kg) daily IV/PO daily (azole, second line) — IDSA 2016 — step-down once stable + susceptible isolate identified; PO has full bioavailability
5. liposomal_amphotericin_B 3-5 mg/kg IV daily IV daily (polyene, rescue) — IDSA 2016 — for refractory disease, deep-seated infection, or pregnancy; nephrotoxicity monitoring
6. voriconazole 6 mg/kg IV q12h × 2 then 3-4 mg/kg q12h IV/PO q12h (azole, add on) — IDSA 2016 — additional CNS / ocular penetration option

Setting playbook (outpatient) — Complete candidemia therapy as OPAT-coordinated echinocandin OR PO fluconazole step-down at home; structured weekly follow-up with culture-driven duration confirmation; repeat blood cultures at 7-14 d post-treatment if endovascular concern; ophthalmologic re-evaluation if endophthalmitis was diagnosed; immunosuppression review + adjustment per host; long-term ID follow-up if endocarditis or chronic source; nutrition optimisation (TPN reduction to reduce recurrence); vaccination review (IDSA 2016 Pappas + OPAT principles)
7. OPAT echinocandin (continuation) Caspofungin 50 mg IV daily OR micafungin 100 mg IV daily OR anidulafungin 100 mg IV daily IV (peripheral or PICC; OPAT setting) daily — Patient stable + clinically improving + OPAT-eligible + species/susceptibility allows continued echinocandin + completing total duration ≥14 d after first negative blood culture (IDSA 2016 Pappas — echinocandin first-line; OPAT delivery proven safe (Norris IDSA OPAT 2018) for daily-dosed echinocandins)
8. PO fluconazole step-down (continuation) 400 mg (6 mg/kg) PO daily; 800 mg (12 mg/kg) load × 1 if not previously loaded PO daily — Stable + species ID confirms fluconazole-susceptible (C. albicans, C. parapsilosis, C. tropicalis; OR C. glabrata MIC ≤ 32) + ≥ 5-7 d echinocandin + sterile blood cultures + clinical improvement + no endocarditis / endophthalmitis / CNS disease (IDSA 2016 Pappas — step-down enables PO completion; full PO bioavailability avoids line for completion)
9. OPAT L-AmB (continuation for endocarditis / endophthalmitis / CNS) 3-5 mg/kg IV daily IV daily — Endocarditis (6 wk total post-valve-replacement) OR endophthalmitis (4-6 wk minimum after stable funduscopy) OR CNS disease — completing prolonged course at home (IDSA 2016 Pappas — L-AmB for deep-seated disease; OPAT delivery with creatinine + K + Mg monitoring)
10. rezafungin once-weekly (alternative OPAT continuation) 200 mg IV q week (after 400 mg load in-hospital) IV weekly — Patient stable + completing total duration + once-weekly OPAT preferred (REVIVE 2023 alternative) (Thompson Lancet 2023 (REVIVE) — non-inferior to caspofungin; reduces OPAT visit frequency to weekly (RxCUI not yet captured — flagged in dossier notes))

Non-pharmacologic actions:
- Line management plan: PICC removed before discharge if completing PO step-down; PICC continued for OPAT if IV-completion required; replaced/exchanged if line was source (Mermel IDSA CRBSI 2009)
- OPAT coordination with home infusion + ID clinic visit at week 1 and week 2 (Norris IDSA OPAT 2018)
- TPN review: wean as enteral nutrition tolerated; reduces candidemia recurrence (IDSA 2016 Pappas)
- Ophthalmologic re-evaluation if endophthalmitis was diagnosed (4-6 wk; intravitreal washout planning if vitritis persists) (IDSA 2016 Pappas)
- Repeat TEE at 4-6 wk if endocarditis was diagnosed; cardiac surgery follow-up (AHA endocarditis 2015 Baddour)
- Immunosuppression coordination (transplant nephrology / heme-onc / rheumatology) — taper/hold/adjust per host (IDSA 2016 Pappas)
- Patient/family education: line care, signs of recurrence (new fever, line-site erythema, persistent fatigue), when to call OPAT/ID, when to return to ED (IDSA 2016 Pappas)
- Vaccination administration if due: PCV20, influenza, COVID-19, herpes zoster, Hib if functionally asplenic (ACIP 2024)
- Advance-care planning / goals-of-care discussion if not addressed during admission (especially for high-mortality survivors) (IDSA 2016 Pappas)

AVOID / contraindication checks:
- Fluconazole block if fluconazole resistant isolate (IDSA 2024)
- Echinocandin not adequate for CNS or ocular disease
- Amphotericin monitor creatinine K Mg (IDSA 2024)
- Voriconazole CYP DDI and TDM target 1 5 (IDSA 2024)
- Central line removal strong non tunneled (IDSA 2024)
- Fluconazole warfarin DDI INR monitoring q3d during overlap
- Fluconazole tacrolimus DDI trough q3d during overlap
- Fluconazole statins DDI hold or switch rosuvastatin pravastatin
- Voriconazole tacrolimus DDI hold tacrolimus during induction or third dose

Monitoring

Regimen monitoring:
- daily blood cultures until 2 consecutive negatives (IDSA 2024)
- ophtho dilated fundoscopy within 1 week repeat at 2 weeks (IDSA 2024)
- TEE if persistent 5d or prosthetic valve (IDSA 2024)
- LFT q3-7d on azole (IDSA 2024)
- creatinine q3-7d on lipid AmB (IDSA 2024)
- duration minimum 14 days after first negative culture (IDSA 2024)
- longer durations for endocarditis endophthalmitis hepatosplenic (IDSA 2024)

Setting (outpatient) monitoring:
- Weekly clinical + lab follow-up: CBC, BMP (renal trend for L-AmB), LFT (azole or echinocandin hepatotoxicity), drug-level if voriconazole (target 1-5.5 mg/L) (IDSA 2016 Pappas)
- Repeat blood cultures at 7-14 d post-treatment if endovascular concern (sustained candidemia history, retained line, endocarditis) (IDSA 2016 Pappas)
- Ophthalmologic re-evaluation at 2-4 wk if endophthalmitis was diagnosed (IDSA 2016 Pappas)
- Repeat TEE at 4-6 wk if endocarditis was diagnosed (IDSA 2016 Pappas; AHA endocarditis 2015 Baddour)
- Drug-interaction monitoring: INR q3d during fluconazole+warfarin overlap; tacrolimus trough q3d during azole overlap; statin DDI hold/switch (DailyMed labels)
- Recurrence surveillance: new fever / chills / line-site erythema / persistent fatigue → return to ED + repeat cultures (IDSA 2016 Pappas)

Follow-up plan: ID outpatient follow-up; species-stewardship feedback; antifungal taper plan (IDSA 2024)
- Close-out criterion: ID f/u scheduled

Monitoring phase: Daily blood cultures until 2 consecutive negatives; LFT q3-7d on azole; renal q3-7d on lipid AmB; ophtho repeat 2 weeks (IDSA 2024)

Disposition

Current setting: outpatient — Complete candidemia therapy as OPAT-coordinated echinocandin OR PO fluconazole step-down at home; structured weekly follow-up with culture-driven duration confirmation; repeat blood cultures at 7-14 d post-treatment if endovascular concern; ophthalmologic re-evaluation if endophthalmitis was diagnosed; immunosuppression review + adjustment per host; long-term ID follow-up if endocarditis or chronic source; nutrition optimisation (TPN reduction to reduce recurrence); vaccination review (IDSA 2016 Pappas + OPAT principles)

Disposition criteria:
- Completion: total duration met (≥ 14 d after first negative blood culture for uncomplicated; ≥ 6 wk for endocarditis; ≥ 4-6 wk for endophthalmitis; ≥ 21 d for CNS / hepatosplenic) + clinical resolution + repeat cultures negative if drawn + ophthalmology cleared + TEE cleared if performed → completion of OPAT, return to standard primary care + relevant specialty (ID for chronic source; cardiology for endocarditis; ophthalmology for endophthalmitis) (IDSA 2016 Pappas)
- Discharge from candidemia-specific surveillance: no recurrence at 6 mo + immunosuppression stable + nutrition optimised + vaccinations up to date (IDSA 2016 Pappas)

Escalation triggers (move to higher acuity):
- New fever / chills / rigors during OPAT → return to ED for recurrent candidemia workup + cultures + line evaluation (IDSA 2016 Pappas)
- New ophthalmologic complaint (eye pain, decreased vision, floaters) → emergent ophthalmology + dilated funduscopy (IDSA 2016 Pappas)
- New cardiac symptoms (new murmur, dyspnea, embolic phenomena) → TEE + ID consult; consider endocarditis (IDSA 2016 Pappas; AHA endocarditis 2015)
- Azole hepatotoxicity (AST/ALT > 5× ULN) → hold azole + switch to echinocandin or L-AmB; hepatology consult if severe (DailyMed labels)
- L-AmB nephrotoxicity (creatinine ≥ 1.5× baseline) → reduce dose / extend interval / switch to echinocandin if species permits (IDSA 2016 Pappas)
- Drug-interaction event (INR > 5, tacrolimus trough > 15, rhabdomyolysis on statin) → adjust per DDI rules + safety consult (DailyMed labels)
- Line dysfunction / line-site infection → IR or vascular consult; consider line removal + alternative access (Mermel IDSA CRBSI 2009)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Hypotension on adequate fluids + lactate >2 + Candida bloodstream infection (IDSA 2024)
- [SEVERE] Non-tunneled central venous catheter still in place 48 h after first positive Candida blood culture (IDSA 2024)
- [SEVERE] Blood cultures still positive 5 days after appropriate echinocandin + line management (IDSA 2024)

Citations

- IDSA 2016 Clinical Practice Guideline for the Management of Candidiasis (Pappas et al, CID 2016) + Mermel IDSA 2009 CRBSI (central-line management) — pending IDSA / ESCMID 2024-2025 update on candidemia and C. auris [PMID:26679628](https://pubmed.ncbi.nlm.nih.gov/26679628/)
- Cited evidence (PMID 19489710) [PMID:19489710](https://pubmed.ncbi.nlm.nih.gov/19489710/)
- Cited evidence (PMID 17568028) [PMID:17568028](https://pubmed.ncbi.nlm.nih.gov/17568028/)

Last reconciled with current guidelines: 2026-05-22.
References
  • IDSA 2016 Clinical Practice Guideline for the Management of Candidiasis (Pappas et al, CID 2016) + Mermel IDSA 2009 CRBSI (central-line management) — pending IDSA / ESCMID 2024-2025 update on candidemia and C. auris — PMID:26679628
  • Cited evidence (PMID 19489710) — PMID:19489710
  • Cited evidence (PMID 17568028) — PMID:17568028