Candidiasis remains a major global health challenge, with rising incidence and antifungal resistance complicating management. This multicenter survey aimed to describe diagnostic and therapeutic management practices of ICU physicians in France for high-risk invasive candidiasis cases, using randomized clinical case simulations distributed to French ICU physicians via email and academic congresses.

A total of 75 physicians completed 283 cases. Overall, clinical suspicion justified diagnostic investigation in 72.1% of cases. Key factors associated with the decision to test for invasive candidiasis included post–abdominal surgery (OR = 3.92; p = 0.002), central venous catheter (OR = 2.28; p = 0.04), parenteral nutrition (OR = 2; p = 0.027), prolonged antibiotic exposure (OR = 1.90; p = 0.041), and physician experience >10 years (OR = 2.79; p = 0.014). Echinocandins were the preferred first-line treatment (88.2%; n = 120/136). Their use was guided by clinical guidelines (78.3%), pharmacokinetic/pharmacodynamic profile (38.3%), SOFA score (29.2%), patient status (25.8%), and immunosuppression (20%). De-escalation to azoles upon documented mycological susceptibility occurred in 87.5% of cases initially treated with an echinocandin and 60.0% of cases initiated on amphotericin B, primarily after 5 days of treatment (51.2%; n = 64).

Patient severity, immunosuppression, and catheter presence were the main factors guiding antifungal treatment decisions Management of confirmed invasive candidiasis was largely consensual among respondents, whereas empirical treatment decisions were heterogeneous. While conclusions are primarily reflective of practice patterns within specialized university hospital centers, the INSPIRE survey highlights the need for enhanced training, broader access to rapid diagnostics, and improved decision-support systems to better harmonize clinical practices.