Invasive candidiasis in intensive care medicine: shaping the future of diagnosis and therapy

Abstract

Background: Invasive candidiasis (IC) remains one of the most challenging infections in critical care, contributing significantly to morbidity, prolonged organ support, and mortality among intensive care unit (ICU) patients. The clinical landscape of IC is evolving, with increasing recognition of Candida non-albicans species and other yeasts formerly classified as Candida spp., alongside emerging multidrug resistance and growing complexity in host immune profiles. Objectives: This contemporary, multidisciplinary narrative review—authored by intensivists, infectious diseases specialists, clinical microbiologists, and pharmacologists—aims to provide ICU clinicians with practical, up-to-date insights into the diagnosis and management of IC. To maintain clinical focus, the review excludes non-IC fungal infections and non-ICU patient populations. Methods: Relevant literature and expert consensus were critically reviewed to summarize current diagnostic and therapeutic approaches for IC in critically ill patients. Emphasis was placed on pragmatic clinical application, diagnostic limitations, antifungal stewardship, and personalized therapeutic decision-making. Results: Despite the availability of novel antifungal agents with improved pharmacokinetic properties, treatment success in IC depends equally on timely and accurate diagnosis and individualized, context-aware therapy. Blood cultures continue to demonstrate limited sensitivity (~40%). Non-culture assays, including β-D-glucan and molecular diagnostics, provide faster detection and high negative predictive value but suffer from low positive predictive value and inconsistent adoption in clinical practice. The absence of validated host-derived biomarkers further limits risk stratification, antifungal discontinuation decisions, and personalized care. Conclusions: Emerging antifungal agents, stewardship strategies, and multidisciplinary care models are essential to improve clinical outcomes and reduce antifungal resistance. This review underscores the need for integrated, teambased diagnostic and therapeutic approaches to close persistent gaps in IC management, ultimately promoting more effective, timely, and individualized care for critically ill patients with Candida spp. infections.