Re-evaluating the 14-day rule: short-course antifungal therapy for uncomplicated candidaemia in a multicentre cohort study

OBJECTIVES: Current guidelines recommend at least 14 days of antifungal therapy for uncomplicated candidaemia after blood culture clearance, despite limited supporting evidence. We evaluated whether antifungal treatment duration was associated with clinical outcomes. METHODS: This multicentre retrospective study in Taiwan (January 2014 to June 2024) included adults with uncomplicated candidaemia (microbiological clearance within 5 days, adequate source control, and no deep-seated or metastatic infection) completing 7-20 days of antifungal therapy. Patients were classified into short-course (7-13 days) and long-course (14-20 days) groups. Primary outcomes were all-cause mortality within 14 days and recurrence within 90 days after the end of treatment (EOT) and secondary outcomes were EOT 90-day mortality and EOT 1-year recurrence. Inverse probability of treatment weighting (IPTW) was applied to adjust for confounders. RESULTS: Among 203 patients, 72 (35.5%) received short-course and 131 (64.5%) long-course therapy. Overall, EOT 14-day mortality was 7.4% (5.6% versus 8.4% in short-course and long-course groups, respectively). Short-course therapy was not associated with increased EOT 14-day mortality in crude (OR 0.64, 95% CI 0.17-1.95), multivariable (aOR 0.33, 95% CI 0.06-1.35), or IPTW-weighted analyses (aOR 0.42, 95% CI 0.11-1.55). The EOT 90-day recurrence rate was 4.4%, with no significant differences across analyses. IPTW-weighted Kaplan-Meier and subgroup analyses showed consistent findings. No significant differences were observed in secondary outcomes, including EOT 90-day mortality and EOT 1-year recurrence. CONCLUSIONS: Short-course antifungal therapy was not associated with increased mortality or recurrence compared with long-course therapy among patients with uncomplicated candidaemia who achieved adequate source control and microbiological clearance.