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.[18][19] 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. In haematopoietic stem cell transplant patients in particular, fluconazole and voriconazole have been shown to be highly effective.[20][21] 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 mould disease (e.g., aspergillosis). Alternate mould-active agents such as posaconazole, voriconazole or an echinocandin may be used for prophylaxis in patients with more prolonged severe neutropenia and at risk of mould infections. Shorter duration neutropenia does not merit prophylaxis as the risk of invasive candidiasis is lower.
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 could be considered for high risk patients, but robust data to support improved clinical outcomes are lacking.[22] Antifungal prophylaxis use must be weighed against the theoretical risk of promoting antifungal resistance.
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 minimising the use of invasive devices, particularly central venous catheters, maintaining proper care of catheters, and avoiding unnecessary antibacterial use.[23]
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 colonisation 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.[16][24]
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