Invasive candidiasis remains a frequent and complex infection encountered in the intensive care unit. The review is a narrative synthesis of English-language literature retrieved via a structured search of PubMed/MEDLINE, Embase and the Cochrane Library covering January 2005 to May 2026. The authors discuss contemporary epidemiologic patterns and note updated fungal nomenclature as context for interpreting diagnostic and surveillance data in critically ill adults.
Critically ill patients present a spectrum of risk factors that predispose to invasive candidiasis, including impaired host immunity, heavy colonization at multiple sites and critical illness–related interventions. The review emphasizes that disease occurs across distinct clinical phenotypes determined by the anatomical source, host responses and iatrogenic factors. Recognizing phenotype-specific presentations is important for guiding diagnostic interpretation and management decisions.
Diagnosis of invasive candidiasis is challenging because clinical manifestations are often nonspecific and positive microbiology or biomarkers may reflect colonization rather than invasive disease. The review examines conventional fungal cultures alongside nonculture diagnostics such as beta-D-glucan assays and molecular tests. The authors underscore diagnostic stewardship: positive cultures or biomarkers should be integrated with the clinical and anatomical context instead of serving as independent triggers for antifungal treatment.
Key diagnostic themes highlighted include careful sampling, interpretation of colonization versus infection, and the potential role of rapid molecular methods to shorten time to pathogen identification. The review does not present specific sensitivity or specificity numbers but stresses that diagnostics must be used within a stewardship framework to avoid overtreatment.
Effective source control is a cornerstone of managing invasive candidiasis in critically ill patients. The review discusses the importance of identifying and managing anatomical foci, with particular attention to intravascular catheters as common sources. Catheter management strategies are considered integral to treatment decisions, and the authors emphasize that source control measures should be timely and tailored to the individual clinical scenario.
Balancing the risks of delayed therapy against unnecessary antifungal exposure is a major therapeutic dilemma. The review contrasts empirical antifungal strategies with targeted therapy driven by microbiological and biomarker data. The authors argue that the essential clinical challenge is not simply avoiding delay in antifungal initiation but ensuring accurate attribution of invasive disease so that therapy is directed to patients who will benefit. Diagnostic stewardship and phenotype recognition are central to making this distinction.
Pharmacologic management in the ICU is complicated by altered pharmacokinetics in critical illness and during extracorporeal support modalities. The review covers the role of therapeutic drug monitoring (TDM) to optimize antifungal exposure and discusses how extracorporeal circuits may affect drug levels. The authors advocate for attention to individualized pharmacokinetic considerations when dosing antifungal agents in critically ill patients, while underscoring TDM as a tool to support precision therapy.
The narrative addresses emerging antifungal therapies and evolving threats, including Candida auris, which poses specific infection control and therapeutic concerns in the ICU setting. The review notes these developments as part of a broader discussion on future directions for antifungal treatment and stewardship, without providing prescriptive treatment algorithms.
The authors’ expert opinion frames the primary challenge in ICU fungal infections as accurate attribution of invasive disease rather than only preventing delay in antifungal therapy. They recommend that future management strategies integrate rapid diagnostics, host immune profiling, optimized pharmacokinetics and effective source control into phenotype-driven approaches. The goal is to improve patient outcomes while strengthening antifungal stewardship to limit unnecessary exposure and preserve antifungal efficacy.
The review synthesizes literature spanning two decades to provide an ICU-focused perspective on invasive candidiasis that emphasizes diagnostic stewardship, precise source control and individualized antifungal therapy. Where the source abstract does not report specific numeric data, sensitivity/specificity values, or detailed treatment protocols, those details are not included here because they were not reported in the source.