\n<\/p>\n
<\/p>\n
\n \n \n Add topic to email alerts \n <\/span> \n <\/p>\n\n\n \n Receive an email when new articles are posted on \n <\/p>\n\n Please provide your email address to receive an email when new articles are posted on .<\/p><\/div>\n<\/p><\/div>\n “ \n data-action=”subscribe”> \n Subscribe \n <\/button>\n <\/div>\n<\/p><\/div>\n We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com.<\/strong> <\/p>\nBack to Healio<\/button><\/p>\n<\/div>\n<\/div><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/div>\n <\/p>\n\n\n More from Column\n <\/div>\nPharmacology Consult<\/h3>\n View all <\/button>\n <\/div>\n <\/p>\nCurrent Infectious Disease Society of America guidelines for the treatment of invasive candidiasis recommend a minimum duration of 14 days after documented clearance of Candida <\/i>species <\/i>from the bloodstream.<\/p>\nThis recommendation has remained the standard of therapy since first applied to the methodology of a randomized controlled trial over 3 decades ago. This recommendation is not without consequence; approximately 1 in 6 patients receiving treatment for invasive candidiasis have hospital admissions prolonged solely for completion of IV antimicrobial therapy, potentially placing patients at higher risk for hospital-acquired infections or further complications. With the increase in azole resistance in Candida glabrata<\/i> and emergence of multidrug-resistant Candida auris<\/i>, it is reasonable to expect this number to increase as more patients require IV agents for effective treatment. [Editor\u2019s note: Under recent taxonomic changes, <\/i>C. glabrata is now known as <\/i>Nakaseomyces glabrata and <\/i>C. auris as <\/i>Candidozyma auris. The editors have opted to use the old names <\/i>for now to avoid confusion.]<\/i><\/p>\n \n \n \n \n <\/source><\/source><\/source><\/source><\/source><\/picture> \n \n <\/figcaption> \n <\/figure>\nIn light of growing evidence demonstrating noninferiority of shorter durations of therapy for infections caused by bacterial organisms, a reexamination of the evidence supporting the recommended duration of therapy for candidemia without metastatic complications is warranted. <\/p>\nDefying the dogma<\/h2>\nDespite the lack of robust trial data to support the 14-day minimum duration, only limited evidence has emerged over the last 30 years to challenge the current dogma. In 1999, a pilot study by Fichtenbaum and colleagues compared 5 to 7 days (short course, SC) with 14 to 20 days of amphotericin B (prolonged course, PC) in non-neutropenic patients with candidemia. To qualify for SC treatment, patients had to have 1 day or more of positive blood cultures, no hypotension and removal of all intravascular catheters; patients without endovascular or other deep-seated infection who did not qualify for SC treatment were included in the PC group. In total, 27 of 29 (93%) in the SC group were clinically cured without relapse at end of follow-up compared with 23 of 29 (79%) in the PC group. Mortality was also numerically lower in the SC group. Generalizing these findings is challenging given the more complicated illness in the PC group, small sample size and retrospective design. Nevertheless, the high cure rate with SC treatment suggests that for carefully selected patients whose blood cultures grow Candida <\/i>and clear promptly (within 1 day), a brief course of antifungals could still provide favorable clinical outcomes.<\/p>\nMore recently, a 2022 retrospective study re-examined the effect of treatment duration on clinical outcomes in a cohort of 114 patients with candidemia without evidence of metastatic or deep-seated infection. In total, 35 patients received SC treatment (5 to 11 days) and 79 received PC treatment (12 to 24 days). Baseline characteristics were well balanced between groups; however, those in the PC group were numerically more likely to receive total parenteral nutrition. At 90 days, no significant difference in mortality was observed between the SC and PC groups; univariable analysis also did not reveal a mortality benefit in patients who received prolonged durations of antifungal therapy. <\/p>\nRecent studies investigating the benefits of guideline adherence have demonstrated similar findings. In 2021, Junco and colleagues reported results from a retrospective study of candidemia treatment comparing 59 patients who received guideline-adherent therapy (GAT) with 227 patients who received guideline non-adherent therapy (GNAT). Severity of illness was similar between groups, although lower rates of central line-associated infection and formal infectious diseases consultation were noted in the GNAT group. No difference between groups was observed in the primary composite outcome of 30-day in-hospital all-cause mortality or 90-day candidemia recurrence. Notably, those in the GNAT group received a median duration of 10.5 days of antifungal therapy after blood culture clearance, significantly less than the GAT group (P <\/i>< .0001). <\/p>\nAlthough these recent studies have similar limitations to those of Fichtenbaum and colleagues, the consistent results further support the idea that for some patients with uncomplicated candidemia, shorter courses of 5 to 10 days may be adequate.<\/p>\nWho gets shorter courses? It\u2019s complicated<\/h2>\nA significant challenge in attempting to apply these results to patient care is determining who would be deemed \u201cuncomplicated\u201d and which patients with candidemia have a higher likelihood of complications. Previous research looking at patients with candidemia defined uncomplicated disease as infection in non-neutropenic patients without endovascular or other deep-seated focus of infection. However, a wide scope of patient- and disease-specific factors may influence the complexity of invasive Candida<\/i> infections. <\/p>\nIn 2025, Reinhold and colleagues proposed a working definition of uncomplicated candidemia in adults. After reviewing six publications, the authors identified specific host, clinical and microbiologic criteria to differentiate uncomplicated from complicated disease. They suggested defining uncomplicated candidemia as the absence of relevant immunosuppression, absence of illicit IV drug use, absence of extra-abdominal deep-seated infections, clinical and mycological response by day 5, and antifungal susceptibility testing availability.<\/p>\nMore data are required to fully characterize the efficacy and safety of shorter treatment durations for uncomplicated candidemia. Standardized definitions such as the one put forward by Reinhold and colleagues can inform the design and conduct of a randomized controlled trial to determine if patients with uncomplicated candidemia are being overtreated under the current guideline-recommended treatment paradigm. In the meantime, infectious diseases clinicians can consider using this definition to promote early identification of patients that may be candidates for shorter courses of antifungal therapy, potentially decreasing length of hospital admission and minimizing the risk for toxicity from antifungal agents. <\/p>\nBased on current evidence, the use of abbreviated courses of antifungal therapy should be limited to patients without overt immunosuppression who have undergone prompt source control with rapid clearance of blood cultures, and only after careful review and discussion of the potential risks and benefits of shorter vs. longer treatment.<\/p>\nFor more information:<\/h2>\n Mason Melbuer, PharmD,<\/b> is a PGY2 infectious diseases pharmacy resident at Providence St. Vincent Medical Center.<\/p>\n Gregory B. Tallman, PharmD, MS, BCPS, BCIDP,<\/b> is a clinical pharmacy specialist in infectious diseases and program director of the PGY2 infectious diseases pharmacy residency at Providence St. Joseph Health. He can be reached at gregory.tallman@providence.org. <\/p>\n <\/p>\n\n\n More from Column\n <\/div>\nPharmacology Consult<\/h3>\n View all <\/button>\n <\/div>\n <\/p>\n
\n Receive an email when new articles are posted on \n <\/p>\n\n Please provide your email address to receive an email when new articles are posted on .<\/p><\/div>\n<\/p><\/div>\n “ \n data-action=”subscribe”> \n Subscribe \n <\/button>\n <\/div>\n<\/p><\/div>\n We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com.<\/strong> <\/p>\nBack to Healio<\/button><\/p>\n<\/div>\n<\/div><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/div>\n <\/p>\n\n\n More from Column\n <\/div>\nPharmacology Consult<\/h3>\n View all <\/button>\n <\/div>\n <\/p>\nCurrent Infectious Disease Society of America guidelines for the treatment of invasive candidiasis recommend a minimum duration of 14 days after documented clearance of Candida <\/i>species <\/i>from the bloodstream.<\/p>\nThis recommendation has remained the standard of therapy since first applied to the methodology of a randomized controlled trial over 3 decades ago. This recommendation is not without consequence; approximately 1 in 6 patients receiving treatment for invasive candidiasis have hospital admissions prolonged solely for completion of IV antimicrobial therapy, potentially placing patients at higher risk for hospital-acquired infections or further complications. With the increase in azole resistance in Candida glabrata<\/i> and emergence of multidrug-resistant Candida auris<\/i>, it is reasonable to expect this number to increase as more patients require IV agents for effective treatment. [Editor\u2019s note: Under recent taxonomic changes, <\/i>C. glabrata is now known as <\/i>Nakaseomyces glabrata and <\/i>C. auris as <\/i>Candidozyma auris. The editors have opted to use the old names <\/i>for now to avoid confusion.]<\/i><\/p>\n \n \n \n \n <\/source><\/source><\/source><\/source><\/source><\/picture> \n \n <\/figcaption> \n <\/figure>\nIn light of growing evidence demonstrating noninferiority of shorter durations of therapy for infections caused by bacterial organisms, a reexamination of the evidence supporting the recommended duration of therapy for candidemia without metastatic complications is warranted. <\/p>\nDefying the dogma<\/h2>\nDespite the lack of robust trial data to support the 14-day minimum duration, only limited evidence has emerged over the last 30 years to challenge the current dogma. In 1999, a pilot study by Fichtenbaum and colleagues compared 5 to 7 days (short course, SC) with 14 to 20 days of amphotericin B (prolonged course, PC) in non-neutropenic patients with candidemia. To qualify for SC treatment, patients had to have 1 day or more of positive blood cultures, no hypotension and removal of all intravascular catheters; patients without endovascular or other deep-seated infection who did not qualify for SC treatment were included in the PC group. In total, 27 of 29 (93%) in the SC group were clinically cured without relapse at end of follow-up compared with 23 of 29 (79%) in the PC group. Mortality was also numerically lower in the SC group. Generalizing these findings is challenging given the more complicated illness in the PC group, small sample size and retrospective design. Nevertheless, the high cure rate with SC treatment suggests that for carefully selected patients whose blood cultures grow Candida <\/i>and clear promptly (within 1 day), a brief course of antifungals could still provide favorable clinical outcomes.<\/p>\nMore recently, a 2022 retrospective study re-examined the effect of treatment duration on clinical outcomes in a cohort of 114 patients with candidemia without evidence of metastatic or deep-seated infection. In total, 35 patients received SC treatment (5 to 11 days) and 79 received PC treatment (12 to 24 days). Baseline characteristics were well balanced between groups; however, those in the PC group were numerically more likely to receive total parenteral nutrition. At 90 days, no significant difference in mortality was observed between the SC and PC groups; univariable analysis also did not reveal a mortality benefit in patients who received prolonged durations of antifungal therapy. <\/p>\nRecent studies investigating the benefits of guideline adherence have demonstrated similar findings. In 2021, Junco and colleagues reported results from a retrospective study of candidemia treatment comparing 59 patients who received guideline-adherent therapy (GAT) with 227 patients who received guideline non-adherent therapy (GNAT). Severity of illness was similar between groups, although lower rates of central line-associated infection and formal infectious diseases consultation were noted in the GNAT group. No difference between groups was observed in the primary composite outcome of 30-day in-hospital all-cause mortality or 90-day candidemia recurrence. Notably, those in the GNAT group received a median duration of 10.5 days of antifungal therapy after blood culture clearance, significantly less than the GAT group (P <\/i>< .0001). <\/p>\nAlthough these recent studies have similar limitations to those of Fichtenbaum and colleagues, the consistent results further support the idea that for some patients with uncomplicated candidemia, shorter courses of 5 to 10 days may be adequate.<\/p>\nWho gets shorter courses? It\u2019s complicated<\/h2>\nA significant challenge in attempting to apply these results to patient care is determining who would be deemed \u201cuncomplicated\u201d and which patients with candidemia have a higher likelihood of complications. Previous research looking at patients with candidemia defined uncomplicated disease as infection in non-neutropenic patients without endovascular or other deep-seated focus of infection. However, a wide scope of patient- and disease-specific factors may influence the complexity of invasive Candida<\/i> infections. <\/p>\nIn 2025, Reinhold and colleagues proposed a working definition of uncomplicated candidemia in adults. After reviewing six publications, the authors identified specific host, clinical and microbiologic criteria to differentiate uncomplicated from complicated disease. They suggested defining uncomplicated candidemia as the absence of relevant immunosuppression, absence of illicit IV drug use, absence of extra-abdominal deep-seated infections, clinical and mycological response by day 5, and antifungal susceptibility testing availability.<\/p>\nMore data are required to fully characterize the efficacy and safety of shorter treatment durations for uncomplicated candidemia. Standardized definitions such as the one put forward by Reinhold and colleagues can inform the design and conduct of a randomized controlled trial to determine if patients with uncomplicated candidemia are being overtreated under the current guideline-recommended treatment paradigm. In the meantime, infectious diseases clinicians can consider using this definition to promote early identification of patients that may be candidates for shorter courses of antifungal therapy, potentially decreasing length of hospital admission and minimizing the risk for toxicity from antifungal agents. <\/p>\nBased on current evidence, the use of abbreviated courses of antifungal therapy should be limited to patients without overt immunosuppression who have undergone prompt source control with rapid clearance of blood cultures, and only after careful review and discussion of the potential risks and benefits of shorter vs. longer treatment.<\/p>\nFor more information:<\/h2>\n Mason Melbuer, PharmD,<\/b> is a PGY2 infectious diseases pharmacy resident at Providence St. Vincent Medical Center.<\/p>\n Gregory B. Tallman, PharmD, MS, BCPS, BCIDP,<\/b> is a clinical pharmacy specialist in infectious diseases and program director of the PGY2 infectious diseases pharmacy residency at Providence St. Joseph Health. He can be reached at gregory.tallman@providence.org. <\/p>\n <\/p>\n\n\n More from Column\n <\/div>\nPharmacology Consult<\/h3>\n View all <\/button>\n <\/div>\n <\/p>\n
“ \n data-action=”subscribe”> \n Subscribe \n <\/button>\n <\/div>\n<\/p><\/div>\n We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com.<\/strong> <\/p>\nBack to Healio<\/button><\/p>\n<\/div>\n<\/div><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/div>\n <\/p>\n\n\n More from Column\n <\/div>\nPharmacology Consult<\/h3>\n View all <\/button>\n <\/div>\n <\/p>\nCurrent Infectious Disease Society of America guidelines for the treatment of invasive candidiasis recommend a minimum duration of 14 days after documented clearance of Candida <\/i>species <\/i>from the bloodstream.<\/p>\nThis recommendation has remained the standard of therapy since first applied to the methodology of a randomized controlled trial over 3 decades ago. This recommendation is not without consequence; approximately 1 in 6 patients receiving treatment for invasive candidiasis have hospital admissions prolonged solely for completion of IV antimicrobial therapy, potentially placing patients at higher risk for hospital-acquired infections or further complications. With the increase in azole resistance in Candida glabrata<\/i> and emergence of multidrug-resistant Candida auris<\/i>, it is reasonable to expect this number to increase as more patients require IV agents for effective treatment. [Editor\u2019s note: Under recent taxonomic changes, <\/i>C. glabrata is now known as <\/i>Nakaseomyces glabrata and <\/i>C. auris as <\/i>Candidozyma auris. The editors have opted to use the old names <\/i>for now to avoid confusion.]<\/i><\/p>\n \n \n \n \n <\/source><\/source><\/source><\/source><\/source><\/picture> \n \n <\/figcaption> \n <\/figure>\nIn light of growing evidence demonstrating noninferiority of shorter durations of therapy for infections caused by bacterial organisms, a reexamination of the evidence supporting the recommended duration of therapy for candidemia without metastatic complications is warranted. <\/p>\nDefying the dogma<\/h2>\nDespite the lack of robust trial data to support the 14-day minimum duration, only limited evidence has emerged over the last 30 years to challenge the current dogma. In 1999, a pilot study by Fichtenbaum and colleagues compared 5 to 7 days (short course, SC) with 14 to 20 days of amphotericin B (prolonged course, PC) in non-neutropenic patients with candidemia. To qualify for SC treatment, patients had to have 1 day or more of positive blood cultures, no hypotension and removal of all intravascular catheters; patients without endovascular or other deep-seated infection who did not qualify for SC treatment were included in the PC group. In total, 27 of 29 (93%) in the SC group were clinically cured without relapse at end of follow-up compared with 23 of 29 (79%) in the PC group. Mortality was also numerically lower in the SC group. Generalizing these findings is challenging given the more complicated illness in the PC group, small sample size and retrospective design. Nevertheless, the high cure rate with SC treatment suggests that for carefully selected patients whose blood cultures grow Candida <\/i>and clear promptly (within 1 day), a brief course of antifungals could still provide favorable clinical outcomes.<\/p>\nMore recently, a 2022 retrospective study re-examined the effect of treatment duration on clinical outcomes in a cohort of 114 patients with candidemia without evidence of metastatic or deep-seated infection. In total, 35 patients received SC treatment (5 to 11 days) and 79 received PC treatment (12 to 24 days). Baseline characteristics were well balanced between groups; however, those in the PC group were numerically more likely to receive total parenteral nutrition. At 90 days, no significant difference in mortality was observed between the SC and PC groups; univariable analysis also did not reveal a mortality benefit in patients who received prolonged durations of antifungal therapy. <\/p>\nRecent studies investigating the benefits of guideline adherence have demonstrated similar findings. In 2021, Junco and colleagues reported results from a retrospective study of candidemia treatment comparing 59 patients who received guideline-adherent therapy (GAT) with 227 patients who received guideline non-adherent therapy (GNAT). Severity of illness was similar between groups, although lower rates of central line-associated infection and formal infectious diseases consultation were noted in the GNAT group. No difference between groups was observed in the primary composite outcome of 30-day in-hospital all-cause mortality or 90-day candidemia recurrence. Notably, those in the GNAT group received a median duration of 10.5 days of antifungal therapy after blood culture clearance, significantly less than the GAT group (P <\/i>< .0001). <\/p>\nAlthough these recent studies have similar limitations to those of Fichtenbaum and colleagues, the consistent results further support the idea that for some patients with uncomplicated candidemia, shorter courses of 5 to 10 days may be adequate.<\/p>\nWho gets shorter courses? It\u2019s complicated<\/h2>\nA significant challenge in attempting to apply these results to patient care is determining who would be deemed \u201cuncomplicated\u201d and which patients with candidemia have a higher likelihood of complications. Previous research looking at patients with candidemia defined uncomplicated disease as infection in non-neutropenic patients without endovascular or other deep-seated focus of infection. However, a wide scope of patient- and disease-specific factors may influence the complexity of invasive Candida<\/i> infections. <\/p>\nIn 2025, Reinhold and colleagues proposed a working definition of uncomplicated candidemia in adults. After reviewing six publications, the authors identified specific host, clinical and microbiologic criteria to differentiate uncomplicated from complicated disease. They suggested defining uncomplicated candidemia as the absence of relevant immunosuppression, absence of illicit IV drug use, absence of extra-abdominal deep-seated infections, clinical and mycological response by day 5, and antifungal susceptibility testing availability.<\/p>\nMore data are required to fully characterize the efficacy and safety of shorter treatment durations for uncomplicated candidemia. Standardized definitions such as the one put forward by Reinhold and colleagues can inform the design and conduct of a randomized controlled trial to determine if patients with uncomplicated candidemia are being overtreated under the current guideline-recommended treatment paradigm. In the meantime, infectious diseases clinicians can consider using this definition to promote early identification of patients that may be candidates for shorter courses of antifungal therapy, potentially decreasing length of hospital admission and minimizing the risk for toxicity from antifungal agents. <\/p>\nBased on current evidence, the use of abbreviated courses of antifungal therapy should be limited to patients without overt immunosuppression who have undergone prompt source control with rapid clearance of blood cultures, and only after careful review and discussion of the potential risks and benefits of shorter vs. longer treatment.<\/p>\nFor more information:<\/h2>\n Mason Melbuer, PharmD,<\/b> is a PGY2 infectious diseases pharmacy resident at Providence St. Vincent Medical Center.<\/p>\n Gregory B. Tallman, PharmD, MS, BCPS, BCIDP,<\/b> is a clinical pharmacy specialist in infectious diseases and program director of the PGY2 infectious diseases pharmacy residency at Providence St. Joseph Health. He can be reached at gregory.tallman@providence.org. <\/p>\n <\/p>\n\n\n More from Column\n <\/div>\nPharmacology Consult<\/h3>\n View all <\/button>\n <\/div>\n <\/p>\n
Back to Healio<\/button><\/p>\n<\/div>\n<\/div><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/div>\n <\/p>\n\n\n More from Column\n <\/div>\nPharmacology Consult<\/h3>\n View all <\/button>\n <\/div>\n <\/p>\nCurrent Infectious Disease Society of America guidelines for the treatment of invasive candidiasis recommend a minimum duration of 14 days after documented clearance of Candida <\/i>species <\/i>from the bloodstream.<\/p>\nThis recommendation has remained the standard of therapy since first applied to the methodology of a randomized controlled trial over 3 decades ago. This recommendation is not without consequence; approximately 1 in 6 patients receiving treatment for invasive candidiasis have hospital admissions prolonged solely for completion of IV antimicrobial therapy, potentially placing patients at higher risk for hospital-acquired infections or further complications. With the increase in azole resistance in Candida glabrata<\/i> and emergence of multidrug-resistant Candida auris<\/i>, it is reasonable to expect this number to increase as more patients require IV agents for effective treatment. [Editor\u2019s note: Under recent taxonomic changes, <\/i>C. glabrata is now known as <\/i>Nakaseomyces glabrata and <\/i>C. auris as <\/i>Candidozyma auris. The editors have opted to use the old names <\/i>for now to avoid confusion.]<\/i><\/p>\n \n \n \n \n <\/source><\/source><\/source><\/source><\/source><\/picture> \n \n <\/figcaption> \n <\/figure>\nIn light of growing evidence demonstrating noninferiority of shorter durations of therapy for infections caused by bacterial organisms, a reexamination of the evidence supporting the recommended duration of therapy for candidemia without metastatic complications is warranted. <\/p>\nDefying the dogma<\/h2>\nDespite the lack of robust trial data to support the 14-day minimum duration, only limited evidence has emerged over the last 30 years to challenge the current dogma. In 1999, a pilot study by Fichtenbaum and colleagues compared 5 to 7 days (short course, SC) with 14 to 20 days of amphotericin B (prolonged course, PC) in non-neutropenic patients with candidemia. To qualify for SC treatment, patients had to have 1 day or more of positive blood cultures, no hypotension and removal of all intravascular catheters; patients without endovascular or other deep-seated infection who did not qualify for SC treatment were included in the PC group. In total, 27 of 29 (93%) in the SC group were clinically cured without relapse at end of follow-up compared with 23 of 29 (79%) in the PC group. Mortality was also numerically lower in the SC group. Generalizing these findings is challenging given the more complicated illness in the PC group, small sample size and retrospective design. Nevertheless, the high cure rate with SC treatment suggests that for carefully selected patients whose blood cultures grow Candida <\/i>and clear promptly (within 1 day), a brief course of antifungals could still provide favorable clinical outcomes.<\/p>\nMore recently, a 2022 retrospective study re-examined the effect of treatment duration on clinical outcomes in a cohort of 114 patients with candidemia without evidence of metastatic or deep-seated infection. In total, 35 patients received SC treatment (5 to 11 days) and 79 received PC treatment (12 to 24 days). Baseline characteristics were well balanced between groups; however, those in the PC group were numerically more likely to receive total parenteral nutrition. At 90 days, no significant difference in mortality was observed between the SC and PC groups; univariable analysis also did not reveal a mortality benefit in patients who received prolonged durations of antifungal therapy. <\/p>\nRecent studies investigating the benefits of guideline adherence have demonstrated similar findings. In 2021, Junco and colleagues reported results from a retrospective study of candidemia treatment comparing 59 patients who received guideline-adherent therapy (GAT) with 227 patients who received guideline non-adherent therapy (GNAT). Severity of illness was similar between groups, although lower rates of central line-associated infection and formal infectious diseases consultation were noted in the GNAT group. No difference between groups was observed in the primary composite outcome of 30-day in-hospital all-cause mortality or 90-day candidemia recurrence. Notably, those in the GNAT group received a median duration of 10.5 days of antifungal therapy after blood culture clearance, significantly less than the GAT group (P <\/i>< .0001). <\/p>\nAlthough these recent studies have similar limitations to those of Fichtenbaum and colleagues, the consistent results further support the idea that for some patients with uncomplicated candidemia, shorter courses of 5 to 10 days may be adequate.<\/p>\nWho gets shorter courses? It\u2019s complicated<\/h2>\nA significant challenge in attempting to apply these results to patient care is determining who would be deemed \u201cuncomplicated\u201d and which patients with candidemia have a higher likelihood of complications. Previous research looking at patients with candidemia defined uncomplicated disease as infection in non-neutropenic patients without endovascular or other deep-seated focus of infection. However, a wide scope of patient- and disease-specific factors may influence the complexity of invasive Candida<\/i> infections. <\/p>\nIn 2025, Reinhold and colleagues proposed a working definition of uncomplicated candidemia in adults. After reviewing six publications, the authors identified specific host, clinical and microbiologic criteria to differentiate uncomplicated from complicated disease. They suggested defining uncomplicated candidemia as the absence of relevant immunosuppression, absence of illicit IV drug use, absence of extra-abdominal deep-seated infections, clinical and mycological response by day 5, and antifungal susceptibility testing availability.<\/p>\nMore data are required to fully characterize the efficacy and safety of shorter treatment durations for uncomplicated candidemia. Standardized definitions such as the one put forward by Reinhold and colleagues can inform the design and conduct of a randomized controlled trial to determine if patients with uncomplicated candidemia are being overtreated under the current guideline-recommended treatment paradigm. In the meantime, infectious diseases clinicians can consider using this definition to promote early identification of patients that may be candidates for shorter courses of antifungal therapy, potentially decreasing length of hospital admission and minimizing the risk for toxicity from antifungal agents. <\/p>\nBased on current evidence, the use of abbreviated courses of antifungal therapy should be limited to patients without overt immunosuppression who have undergone prompt source control with rapid clearance of blood cultures, and only after careful review and discussion of the potential risks and benefits of shorter vs. longer treatment.<\/p>\nFor more information:<\/h2>\n Mason Melbuer, PharmD,<\/b> is a PGY2 infectious diseases pharmacy resident at Providence St. Vincent Medical Center.<\/p>\n Gregory B. Tallman, PharmD, MS, BCPS, BCIDP,<\/b> is a clinical pharmacy specialist in infectious diseases and program director of the PGY2 infectious diseases pharmacy residency at Providence St. Joseph Health. He can be reached at gregory.tallman@providence.org. <\/p>\n <\/p>\n\n\n More from Column\n <\/div>\nPharmacology Consult<\/h3>\n View all <\/button>\n <\/div>\n <\/p>\n
View all <\/button>\n <\/div>\n <\/p>\nCurrent Infectious Disease Society of America guidelines for the treatment of invasive candidiasis recommend a minimum duration of 14 days after documented clearance of Candida <\/i>species <\/i>from the bloodstream.<\/p>\nThis recommendation has remained the standard of therapy since first applied to the methodology of a randomized controlled trial over 3 decades ago. This recommendation is not without consequence; approximately 1 in 6 patients receiving treatment for invasive candidiasis have hospital admissions prolonged solely for completion of IV antimicrobial therapy, potentially placing patients at higher risk for hospital-acquired infections or further complications. With the increase in azole resistance in Candida glabrata<\/i> and emergence of multidrug-resistant Candida auris<\/i>, it is reasonable to expect this number to increase as more patients require IV agents for effective treatment. [Editor\u2019s note: Under recent taxonomic changes, <\/i>C. glabrata is now known as <\/i>Nakaseomyces glabrata and <\/i>C. auris as <\/i>Candidozyma auris. The editors have opted to use the old names <\/i>for now to avoid confusion.]<\/i><\/p>\n \n \n \n \n <\/source><\/source><\/source><\/source><\/source><\/picture> \n \n <\/figcaption> \n <\/figure>\nIn light of growing evidence demonstrating noninferiority of shorter durations of therapy for infections caused by bacterial organisms, a reexamination of the evidence supporting the recommended duration of therapy for candidemia without metastatic complications is warranted. <\/p>\nDefying the dogma<\/h2>\nDespite the lack of robust trial data to support the 14-day minimum duration, only limited evidence has emerged over the last 30 years to challenge the current dogma. In 1999, a pilot study by Fichtenbaum and colleagues compared 5 to 7 days (short course, SC) with 14 to 20 days of amphotericin B (prolonged course, PC) in non-neutropenic patients with candidemia. To qualify for SC treatment, patients had to have 1 day or more of positive blood cultures, no hypotension and removal of all intravascular catheters; patients without endovascular or other deep-seated infection who did not qualify for SC treatment were included in the PC group. In total, 27 of 29 (93%) in the SC group were clinically cured without relapse at end of follow-up compared with 23 of 29 (79%) in the PC group. Mortality was also numerically lower in the SC group. Generalizing these findings is challenging given the more complicated illness in the PC group, small sample size and retrospective design. Nevertheless, the high cure rate with SC treatment suggests that for carefully selected patients whose blood cultures grow Candida <\/i>and clear promptly (within 1 day), a brief course of antifungals could still provide favorable clinical outcomes.<\/p>\nMore recently, a 2022 retrospective study re-examined the effect of treatment duration on clinical outcomes in a cohort of 114 patients with candidemia without evidence of metastatic or deep-seated infection. In total, 35 patients received SC treatment (5 to 11 days) and 79 received PC treatment (12 to 24 days). Baseline characteristics were well balanced between groups; however, those in the PC group were numerically more likely to receive total parenteral nutrition. At 90 days, no significant difference in mortality was observed between the SC and PC groups; univariable analysis also did not reveal a mortality benefit in patients who received prolonged durations of antifungal therapy. <\/p>\nRecent studies investigating the benefits of guideline adherence have demonstrated similar findings. In 2021, Junco and colleagues reported results from a retrospective study of candidemia treatment comparing 59 patients who received guideline-adherent therapy (GAT) with 227 patients who received guideline non-adherent therapy (GNAT). Severity of illness was similar between groups, although lower rates of central line-associated infection and formal infectious diseases consultation were noted in the GNAT group. No difference between groups was observed in the primary composite outcome of 30-day in-hospital all-cause mortality or 90-day candidemia recurrence. Notably, those in the GNAT group received a median duration of 10.5 days of antifungal therapy after blood culture clearance, significantly less than the GAT group (P <\/i>< .0001). <\/p>\nAlthough these recent studies have similar limitations to those of Fichtenbaum and colleagues, the consistent results further support the idea that for some patients with uncomplicated candidemia, shorter courses of 5 to 10 days may be adequate.<\/p>\nWho gets shorter courses? It\u2019s complicated<\/h2>\nA significant challenge in attempting to apply these results to patient care is determining who would be deemed \u201cuncomplicated\u201d and which patients with candidemia have a higher likelihood of complications. Previous research looking at patients with candidemia defined uncomplicated disease as infection in non-neutropenic patients without endovascular or other deep-seated focus of infection. However, a wide scope of patient- and disease-specific factors may influence the complexity of invasive Candida<\/i> infections. <\/p>\nIn 2025, Reinhold and colleagues proposed a working definition of uncomplicated candidemia in adults. After reviewing six publications, the authors identified specific host, clinical and microbiologic criteria to differentiate uncomplicated from complicated disease. They suggested defining uncomplicated candidemia as the absence of relevant immunosuppression, absence of illicit IV drug use, absence of extra-abdominal deep-seated infections, clinical and mycological response by day 5, and antifungal susceptibility testing availability.<\/p>\nMore data are required to fully characterize the efficacy and safety of shorter treatment durations for uncomplicated candidemia. Standardized definitions such as the one put forward by Reinhold and colleagues can inform the design and conduct of a randomized controlled trial to determine if patients with uncomplicated candidemia are being overtreated under the current guideline-recommended treatment paradigm. In the meantime, infectious diseases clinicians can consider using this definition to promote early identification of patients that may be candidates for shorter courses of antifungal therapy, potentially decreasing length of hospital admission and minimizing the risk for toxicity from antifungal agents. <\/p>\nBased on current evidence, the use of abbreviated courses of antifungal therapy should be limited to patients without overt immunosuppression who have undergone prompt source control with rapid clearance of blood cultures, and only after careful review and discussion of the potential risks and benefits of shorter vs. longer treatment.<\/p>\nFor more information:<\/h2>\n Mason Melbuer, PharmD,<\/b> is a PGY2 infectious diseases pharmacy resident at Providence St. Vincent Medical Center.<\/p>\n Gregory B. Tallman, PharmD, MS, BCPS, BCIDP,<\/b> is a clinical pharmacy specialist in infectious diseases and program director of the PGY2 infectious diseases pharmacy residency at Providence St. Joseph Health. He can be reached at gregory.tallman@providence.org. <\/p>\n <\/p>\n\n\n More from Column\n <\/div>\nPharmacology Consult<\/h3>\n View all <\/button>\n <\/div>\n <\/p>\n
Current Infectious Disease Society of America guidelines for the treatment of invasive candidiasis recommend a minimum duration of 14 days after documented clearance of Candida <\/i>species <\/i>from the bloodstream.<\/p>\n
This recommendation has remained the standard of therapy since first applied to the methodology of a randomized controlled trial over 3 decades ago. This recommendation is not without consequence; approximately 1 in 6 patients receiving treatment for invasive candidiasis have hospital admissions prolonged solely for completion of IV antimicrobial therapy, potentially placing patients at higher risk for hospital-acquired infections or further complications. With the increase in azole resistance in Candida glabrata<\/i> and emergence of multidrug-resistant Candida auris<\/i>, it is reasonable to expect this number to increase as more patients require IV agents for effective treatment. [Editor\u2019s note: Under recent taxonomic changes, <\/i>C. glabrata is now known as <\/i>Nakaseomyces glabrata and <\/i>C. auris as <\/i>Candidozyma auris. The editors have opted to use the old names <\/i>for now to avoid confusion.]<\/i><\/p>\n \n \n \n \n <\/source><\/source><\/source><\/source><\/source><\/picture> \n \n <\/figcaption> \n <\/figure>\nIn light of growing evidence demonstrating noninferiority of shorter durations of therapy for infections caused by bacterial organisms, a reexamination of the evidence supporting the recommended duration of therapy for candidemia without metastatic complications is warranted. <\/p>\nDefying the dogma<\/h2>\nDespite the lack of robust trial data to support the 14-day minimum duration, only limited evidence has emerged over the last 30 years to challenge the current dogma. In 1999, a pilot study by Fichtenbaum and colleagues compared 5 to 7 days (short course, SC) with 14 to 20 days of amphotericin B (prolonged course, PC) in non-neutropenic patients with candidemia. To qualify for SC treatment, patients had to have 1 day or more of positive blood cultures, no hypotension and removal of all intravascular catheters; patients without endovascular or other deep-seated infection who did not qualify for SC treatment were included in the PC group. In total, 27 of 29 (93%) in the SC group were clinically cured without relapse at end of follow-up compared with 23 of 29 (79%) in the PC group. Mortality was also numerically lower in the SC group. Generalizing these findings is challenging given the more complicated illness in the PC group, small sample size and retrospective design. Nevertheless, the high cure rate with SC treatment suggests that for carefully selected patients whose blood cultures grow Candida <\/i>and clear promptly (within 1 day), a brief course of antifungals could still provide favorable clinical outcomes.<\/p>\nMore recently, a 2022 retrospective study re-examined the effect of treatment duration on clinical outcomes in a cohort of 114 patients with candidemia without evidence of metastatic or deep-seated infection. In total, 35 patients received SC treatment (5 to 11 days) and 79 received PC treatment (12 to 24 days). Baseline characteristics were well balanced between groups; however, those in the PC group were numerically more likely to receive total parenteral nutrition. At 90 days, no significant difference in mortality was observed between the SC and PC groups; univariable analysis also did not reveal a mortality benefit in patients who received prolonged durations of antifungal therapy. <\/p>\nRecent studies investigating the benefits of guideline adherence have demonstrated similar findings. In 2021, Junco and colleagues reported results from a retrospective study of candidemia treatment comparing 59 patients who received guideline-adherent therapy (GAT) with 227 patients who received guideline non-adherent therapy (GNAT). Severity of illness was similar between groups, although lower rates of central line-associated infection and formal infectious diseases consultation were noted in the GNAT group. No difference between groups was observed in the primary composite outcome of 30-day in-hospital all-cause mortality or 90-day candidemia recurrence. Notably, those in the GNAT group received a median duration of 10.5 days of antifungal therapy after blood culture clearance, significantly less than the GAT group (P <\/i>< .0001). <\/p>\nAlthough these recent studies have similar limitations to those of Fichtenbaum and colleagues, the consistent results further support the idea that for some patients with uncomplicated candidemia, shorter courses of 5 to 10 days may be adequate.<\/p>\nWho gets shorter courses? It\u2019s complicated<\/h2>\nA significant challenge in attempting to apply these results to patient care is determining who would be deemed \u201cuncomplicated\u201d and which patients with candidemia have a higher likelihood of complications. Previous research looking at patients with candidemia defined uncomplicated disease as infection in non-neutropenic patients without endovascular or other deep-seated focus of infection. However, a wide scope of patient- and disease-specific factors may influence the complexity of invasive Candida<\/i> infections. <\/p>\nIn 2025, Reinhold and colleagues proposed a working definition of uncomplicated candidemia in adults. After reviewing six publications, the authors identified specific host, clinical and microbiologic criteria to differentiate uncomplicated from complicated disease. They suggested defining uncomplicated candidemia as the absence of relevant immunosuppression, absence of illicit IV drug use, absence of extra-abdominal deep-seated infections, clinical and mycological response by day 5, and antifungal susceptibility testing availability.<\/p>\nMore data are required to fully characterize the efficacy and safety of shorter treatment durations for uncomplicated candidemia. Standardized definitions such as the one put forward by Reinhold and colleagues can inform the design and conduct of a randomized controlled trial to determine if patients with uncomplicated candidemia are being overtreated under the current guideline-recommended treatment paradigm. In the meantime, infectious diseases clinicians can consider using this definition to promote early identification of patients that may be candidates for shorter courses of antifungal therapy, potentially decreasing length of hospital admission and minimizing the risk for toxicity from antifungal agents. <\/p>\nBased on current evidence, the use of abbreviated courses of antifungal therapy should be limited to patients without overt immunosuppression who have undergone prompt source control with rapid clearance of blood cultures, and only after careful review and discussion of the potential risks and benefits of shorter vs. longer treatment.<\/p>\nFor more information:<\/h2>\n Mason Melbuer, PharmD,<\/b> is a PGY2 infectious diseases pharmacy resident at Providence St. Vincent Medical Center.<\/p>\n Gregory B. Tallman, PharmD, MS, BCPS, BCIDP,<\/b> is a clinical pharmacy specialist in infectious diseases and program director of the PGY2 infectious diseases pharmacy residency at Providence St. Joseph Health. He can be reached at gregory.tallman@providence.org. <\/p>\n <\/p>\n\n\n More from Column\n <\/div>\nPharmacology Consult<\/h3>\n View all <\/button>\n <\/div>\n <\/p>\n
In light of growing evidence demonstrating noninferiority of shorter durations of therapy for infections caused by bacterial organisms, a reexamination of the evidence supporting the recommended duration of therapy for candidemia without metastatic complications is warranted. <\/p>\n
Despite the lack of robust trial data to support the 14-day minimum duration, only limited evidence has emerged over the last 30 years to challenge the current dogma. In 1999, a pilot study by Fichtenbaum and colleagues compared 5 to 7 days (short course, SC) with 14 to 20 days of amphotericin B (prolonged course, PC) in non-neutropenic patients with candidemia. To qualify for SC treatment, patients had to have 1 day or more of positive blood cultures, no hypotension and removal of all intravascular catheters; patients without endovascular or other deep-seated infection who did not qualify for SC treatment were included in the PC group. In total, 27 of 29 (93%) in the SC group were clinically cured without relapse at end of follow-up compared with 23 of 29 (79%) in the PC group. Mortality was also numerically lower in the SC group. Generalizing these findings is challenging given the more complicated illness in the PC group, small sample size and retrospective design. Nevertheless, the high cure rate with SC treatment suggests that for carefully selected patients whose blood cultures grow Candida <\/i>and clear promptly (within 1 day), a brief course of antifungals could still provide favorable clinical outcomes.<\/p>\n
More recently, a 2022 retrospective study re-examined the effect of treatment duration on clinical outcomes in a cohort of 114 patients with candidemia without evidence of metastatic or deep-seated infection. In total, 35 patients received SC treatment (5 to 11 days) and 79 received PC treatment (12 to 24 days). Baseline characteristics were well balanced between groups; however, those in the PC group were numerically more likely to receive total parenteral nutrition. At 90 days, no significant difference in mortality was observed between the SC and PC groups; univariable analysis also did not reveal a mortality benefit in patients who received prolonged durations of antifungal therapy. <\/p>\n
Recent studies investigating the benefits of guideline adherence have demonstrated similar findings. In 2021, Junco and colleagues reported results from a retrospective study of candidemia treatment comparing 59 patients who received guideline-adherent therapy (GAT) with 227 patients who received guideline non-adherent therapy (GNAT). Severity of illness was similar between groups, although lower rates of central line-associated infection and formal infectious diseases consultation were noted in the GNAT group. No difference between groups was observed in the primary composite outcome of 30-day in-hospital all-cause mortality or 90-day candidemia recurrence. Notably, those in the GNAT group received a median duration of 10.5 days of antifungal therapy after blood culture clearance, significantly less than the GAT group (P <\/i>< .0001). <\/p>\n
Although these recent studies have similar limitations to those of Fichtenbaum and colleagues, the consistent results further support the idea that for some patients with uncomplicated candidemia, shorter courses of 5 to 10 days may be adequate.<\/p>\n
A significant challenge in attempting to apply these results to patient care is determining who would be deemed \u201cuncomplicated\u201d and which patients with candidemia have a higher likelihood of complications. Previous research looking at patients with candidemia defined uncomplicated disease as infection in non-neutropenic patients without endovascular or other deep-seated focus of infection. However, a wide scope of patient- and disease-specific factors may influence the complexity of invasive Candida<\/i> infections. <\/p>\n
In 2025, Reinhold and colleagues proposed a working definition of uncomplicated candidemia in adults. After reviewing six publications, the authors identified specific host, clinical and microbiologic criteria to differentiate uncomplicated from complicated disease. They suggested defining uncomplicated candidemia as the absence of relevant immunosuppression, absence of illicit IV drug use, absence of extra-abdominal deep-seated infections, clinical and mycological response by day 5, and antifungal susceptibility testing availability.<\/p>\n
More data are required to fully characterize the efficacy and safety of shorter treatment durations for uncomplicated candidemia. Standardized definitions such as the one put forward by Reinhold and colleagues can inform the design and conduct of a randomized controlled trial to determine if patients with uncomplicated candidemia are being overtreated under the current guideline-recommended treatment paradigm. In the meantime, infectious diseases clinicians can consider using this definition to promote early identification of patients that may be candidates for shorter courses of antifungal therapy, potentially decreasing length of hospital admission and minimizing the risk for toxicity from antifungal agents. <\/p>\n
Based on current evidence, the use of abbreviated courses of antifungal therapy should be limited to patients without overt immunosuppression who have undergone prompt source control with rapid clearance of blood cultures, and only after careful review and discussion of the potential risks and benefits of shorter vs. longer treatment.<\/p>\n
Mason Melbuer, PharmD,<\/b> is a PGY2 infectious diseases pharmacy resident at Providence St. Vincent Medical Center.<\/p>\n
Gregory B. Tallman, PharmD, MS, BCPS, BCIDP,<\/b> is a clinical pharmacy specialist in infectious diseases and program director of the PGY2 infectious diseases pharmacy residency at Providence St. Joseph Health. He can be reached at gregory.tallman@providence.org. <\/p>\n
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