Primary prevention

Primary prevention is feasible given the well-tolerated and effective antifungal agents available. Systemic antifungal prophylaxis has been shown to reduce the risk for invasive Candida infections in neutropenic patients, though overall mortality is not affected.[24][25]​​​​ Prophylactic antifungals are recommended in patients at high risk of invasive candidiasis (generally defined as >10% incidence of disease). A common scenario is patients with chemotherapy-induced neutropenia likely to persist longer than 7 days.[26]​ In hematopoietic stem cell transplant patients in particular, fluconazole, micafungin, voriconazole, and posaconazole have been shown to be highly effective in preventing Candida infection.[27][28][29]​​​​​ Duration of prophylaxis in allogeneic stem cell transplant is typically 75-100 days post transplant. However, in autologous stem cell transplant antifungal prophylaxis can be discontinued in most cases as soon as neutropenia resolves.[29]​ Fluconazole is widely used in neutropenic patients and in postoperative solid organ transplant patients at risk of developing invasive candidiasis. For patients with myelodysplasia and long-term neutropenia, fluconazole may be inadequate for preventing invasive mold disease (e.g., aspergillosis). Alternate mold-active agents such as posaconazole, voriconazole or an echinocandin should be considered in all patients with more prolonged severe neutropenia and at risk of mold infections in addition to risk of candidiasis. Shorter duration neutropenia does not merit prophylaxis as the risk of invasive candidiasis is lower.[26]

One subgroup analysis of a prospective, multicenter observational registry-based study looking at breakthrough fungal infections in patients receiving mold-active azole antifungals (i.e., voriconazole, posaconazole, isavuconazonium) found that such infections were uncommon (occurring in 7.1% of patients). However, 36.1% of breakthrough infections were related to Candida. Candida was the most common fungal breakthrough infection in the posaconazole group (55.6%) and Candida glabrata accounted for 30% of breakthrough infections in the isavuconazonium group (3 out of 10).[30]

For solid organ transplant recipients, Candida prophylaxis is usually reserved for high-risk patients based on risk factors specific to each organ, with heart and kidney transplant recipients being at lowest risk. Fluconazole is typically used if there are no risk factors for mold infections. Duration may be around 4 weeks post transplant.[31]

A key issue in non-transplant intensive care unit (ICU) patients is identifying those with the highest risk who would benefit the most from a prophylactic regimen. In ICUs with high rates of invasive candidiasis (>5%), prophylaxis with fluconazole or an echinocandin (e.g., caspofungin) could be considered for high risk patients, but robust data to support improved clinical outcomes are lacking.[32]​ One randomized, double-blind, placebo-controlled trial evaluated caspofungin prophylaxis in high-risk patients in the ICU, including those with prolonged ICU stays, mechanical ventilation, and additional risk factors such as parenteral nutrition, dialysis, or recent surgery. The study found that while caspofungin tended to reduce the incidence of invasive candidiasis, the difference was not statistically significant.[33]​ Antifungal prophylaxis use must be weighed against the theoretical risk of promoting antifungal resistance. 

The most recent guidelines from the International Society of Peritoneal Dialysis recommends prophylaxis with nystatin or fluconazole during any antibiotic administration to patients on peritoneal dialysis to prevent fungal peritonitis.[34]

Modifiable risk factors should also be addressed at the patient and institution levels. Adhering to strong infection prevention and antibiotic stewardship practices can mitigate some of the risks associated with invasive candidiasis. Examples include minimizing the use of invasive devices, particularly central venous catheters, maintaining proper care of catheters, and avoiding unnecessary antibacterial use.[35]

Hospitals are advised to institute specific infection control measures when Candida auris is isolated. These include: contact precautions, often for prolonged periods or indefinitely as colonization persists; the use of dedicated patient equipment; and cleaning and disinfecting the patient care environment with products on the US Environmental Protection Agency's List P (effective kill claim for Candida auris) or List K (effective against Clostridium difficile spores) if List P items are not available, as standard disinfectants may not eradicate the organism.​[19][36]

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