What are the recommended first-line antifungal treatments for patients diagnosed with invasive candidiasis?

First-line antifungal treatments for invasive candidiasis typically include echinocandins such as caspofungin, micafungin, or anidulafungin, which are recommended due to their broad spectrum of activity and favourable safety profile. These agents are preferred initially, especially in critically ill patients or those with prior azole exposure, as they provide effective coverage against most Candida species including those resistant to azoles NICE NG78. Fluconazole is an alternative first-line option in clinically stable patients without recent azole exposure and where Candida species are known or likely to be susceptible. This approach balances efficacy with considerations of toxicity and resistance patterns NICE NG78.

In paediatric and immunocompromised populations, such as hematopoietic stem cell transplant recipients, echinocandins remain the cornerstone of initial therapy, supported by ECIL-6 guidelines, with step-down to fluconazole guided by species identification and susceptibility testing Tissot et al. 2017. Recent literature also highlights the evolving epidemiology of invasive candidiasis and the importance of early initiation of echinocandins to improve outcomes, particularly in critically ill children and adults Hon et al. 2024Bassetti et al. 2018.

Amphotericin B formulations may be considered in cases of intolerance or resistance to echinocandins and azoles, but are generally reserved due to toxicity concerns. Overall, treatment choice should be guided by local epidemiology, patient factors, and antifungal susceptibility results when available NICE NG78; Bassetti et al. 2018.