Candidiasis

Aka: Candidiasis, Moniliasis, Urinary Tract Candidiasis, Candiduria, Esophageal Candidiasis, Pseudomembranous Candidiasis

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II. Etiology

  1. Candida albicans

III. Risk Factors

  1. Skin maceration
  2. Immunosuppressed patients
    1. Advanced Human Immunodeficiency Virus or AIDS (esp. CD4 Count <200 cells/uL)
    2. Hematologic Malignancy
    3. Antibiotic use
    4. Corticosteroid use
    5. Pregnancy
    6. Diabetes Mellitus

IV. Signs: Systemic involvement in Immunocompromised patient

  1. Severe Muscle tenderness

V. Signs: Mucocutaneous Rash

  1. Character
    1. Erythematous Papules
    2. Pruritic, eroded areas
    3. Scaling and crusting of lesions
  2. Normal Distribution (Not Immunocompromised)
    1. Mouth
    2. Vagina
    3. Axillae
    4. Inguinal folds
    5. Interdigital surfaces

VI. Signs: Specific Lesions

  1. Oral Thrush
    1. Pseudomembranous Candidiasis
      1. Painless, white Plaques firmly adhered to oral or pharyngeal mucosa
      2. Plaques can be easily scraped from surface
    2. Erythematous Candidiasis (less common)
      1. Erythema and pain, without Plaques
  2. Cutaneous Candidiasis
    1. Red, macerated intertriginous areas
  3. Chronic mucocutaneous Candidiasis
    1. Circumscribed hyperkeratotic skin lesions
    2. Dystrophic Nails
    3. Partial Alopecia
    4. Oral and vaginal Thrush
    5. Endocrine organ hypofunction
      1. Hypoparathyroidism
      2. Hypothyroidism
      3. Adrenal Insufficiency
  4. Esophageal Candidiasis
    1. Distal Esophagus ulcerations
    2. Associated with Dysphagia, odynaphagia and substernal pain
  5. Hematogenous (Immunosuppressed)
    1. Fever
    2. Malaise
    3. Retinal abscess
    4. Pulmonary nodular infiltrate
    5. Endocarditis

VII. Labs

  1. Abscess drainage shows candida mycelia
  2. Candida Serology titers elevated
  3. KOH Preparation
    1. Pseudohyphae

VIII. Management: General

  1. Cutaneous
    1. Nystatin
    2. Ciclopirox
    3. Imidazole cream
  2. Oral Thrush
    1. Fluconazole 100 mg orally daily for 7 to 14 days
      1. Preferred first-line option
    2. Clotrimazole Troches
      1. One troche dissolve in mouth 5 times daily for 7 to 14 days
    3. Nystatin suspension
      1. Swish and swallow 4 to 6 times per day for 7 to 14 days
  3. Esophageal
    1. Fluconazole 100 to 200 mg oral or IV daily for 14 to 21 days
    2. Other alternative azoles
      1. Intraconazole orally
      2. Voriconazole or Isavuconazole IV
    3. Other agents with higher toxicity
      1. Amphotericin B 0.3 mg/kg/day for 5 to 10 days
        1. Indicated for severe cases only
      2. Ketoconazole 200 to 400 mg orally daily for 14 to 21 days
        1. Indicated only for severe, refractory cases due to Ketoconazole hepatotoxicity
        2. If Ketoconazole is used, requires Liver Function Tests at baseline and again weekly
    4. Refractory cases
      1. Expect symptoms to start to improve within 3 days of starting medications (e.g. Fluconazole)
      2. Upper endoscopy is only indicated for persistent symptoms despite empiric Antifungal therapy
      3. Consider non-albicans species or resistant Candida albicans in refractory cases

IX. Management: Urinary Tract Candidiasis (Candiduria)

  1. Asymptomatic Candiduria (on Urinalysis) does not require treatment unless otherwise indicated
  2. Pre-Urologic procedure and Candiduria
    1. Fluconazole (Diflucan) 3-6 mg/kg to 200 to 400 mg orally or IV once daily for 2 to 3 days before and after procedure OR
    2. Amphotericin B 0.3 to 0.6 mg/kg once daily for 2 to 3 days before and after procedure
  3. Symptomatic Candiduria (or asymptomatic with risks)
    1. Indications for treatment in asymptomatic patients
      1. Neutropenia
      2. Low Birth Weight Infant
      3. Pregnancy
    2. First-line agents
      1. Fluconazole (Diflucan) 3 mg/kg up to 200 mg orally or IV once daily for 14 days
        1. Increase dose to 6 mg/kg up to 400 mg orally daily for Pyelonephritis
    3. Alternative Agents (e.g. Fluconazole resistance)
      1. Amphotericin B 0.5 mg/kg once daily for 7 days (14 days for Pyelonephritis) OR
        1. If Urinary Catheter, may irrigate with Amphotericin B 50 mg in 1L x5-7 days
      2. Flucytosine 25 mg/kg four times daily for 14 days
  4. References
    1. Fisher (2011) Clin Infect Dis 52 (Suppl 6):S457-66 +PMID:21498839 [PubMed]
      1. https://academic.oup.com/cid/article/52/suppl_6/S457/285164

X. Management: Disseminated

  1. Empiric broad Candidiasis coverage or known resistant Candidiasis (Candida glabrata or Candida krusei)
    1. Caspofungin 70 mg IV load, then 50 mg IV every 24 hours or
    2. Micafungin 100 mg IV every 24 hours or
    3. Anidulafungin 200 mg IV load, then 100 mg IV every 24 hours
  2. Known Candida albicans or Candida parapsilosis or Candida tropicalis
    1. Fluconazole 800 mg (12 mg/kg) load then 400 mg IV or oral daily
  3. Alternative empiric protocols
    1. Amphotericin B 0.7 mg/kg IV daily (or lipid based Amphotericin B 3-5 mg/kg daily) or
    2. Fluconazole 800 mg (or 12 mg/kg) load then 400 mg IV or oral daily or
    3. Voriconazole 400 mg (or 6 mg/kg) IV twice daily for 2 doses, followed by 200 mg every 12 hours
  4. References
    1. Gilbert (2013) Sanford Antibiotic Guide

XI. References

  1. Parker and Bond (2023) Crit Dec Emerg Med 37(10): 4-9

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Related Studies

Ontology: Candidiasis (C0006840)

Definition (NCI_NCI-GLOSS) A condition in which Candida albicans, a type of yeast, grows out of control in moist skin areas of the body. It is usually a result of a weakened immune system, but can be a side effect of chemotherapy or treatment with antibiotics. Thrush usually affects the mouth (oral thrush); however, rarely, it spreads throughout the entire body.
Definition (MSH) Infection with a fungus of the genus CANDIDA. It is usually a superficial infection of the moist areas of the body and is generally caused by CANDIDA ALBICANS. (Dorland, 27th ed)
Definition (CSP) infection with a fungus of the genus Candida; usually a superficial infection of the moist areas of the body and is generally caused by Candida albicans; includes chronic mucocutaneous candidiasis, cutaneous candidiasis, oral candidiasis (thrush), and monilial vaginitis.
Concepts Disease or Syndrome (T047)
MSH D002177
ICD9 112.9, 112
ICD10 B37 , B37.9
SnomedCT 187005005, 187024008, 187478002, 154403005, 370520002, 78048006
English Candidiases, Candidiasis, Moniliases, Moniliasis, CANDIDIASIS, MONILIASIS, Candidiasis, unspecified, [X]Candidiasis, unspecified, candidiasis, candidiasis (diagnosis), Candida infections, Candidiasis site NOS, candidosis, Candidiasis [Disease/Finding], candidal infection, candidal infections, monilial infection, thrush, candida infections, candidiases, candida infection, muguet, monilia infection, Candidiasis NOS (disorder), [X]Candidiasis, unspecified (disorder), Candida NOS, Monilial infection, Moniliasis monilia, Moniliasis NOS, Candidiasis of unspecified site, Monilia NOS, Candidal infection NOS, Candidiasis NOS, Thrush, Candidosis, Infection by Candida species, Candida infection, Monilia infection, Candidiasis (disorder), moniliasis, candida; infection, Muguet, infection; candidal, infection; monilia, monilia; infection, Candidiasis, NOS, Candidosis, NOS, Moniliasis, NOS
French CANDIDOSE, MONILIASE, Infection candidosique, Infection à Candida, Candidiase SAI, Candidose SAI, Candida SAI, Infection à Candida SAI, Moniliase SAI, Candidose de site non précisé, Moniliase à Candida, Candidoses, Candidiase, Candidose, Moniliase, Moniliose
Portuguese CANDIDIASE, MONILIASE, Candidíase NE, Candidiase, Monilia NE, Candida NE, Monilia de monilíase, Infecção por Candida, Infecção por cândida NE, Candidíase de local NE, Infecção por monilia, Monilíase NE, Infecções a Candida, Candidíase, Monilíase
Spanish CANDIDIASIS, MONILIASIS, [X]candidiasis, no especificada (trastorno), moliniasis, SAI, candidiasis, SAI, candidiasis, SAI (trastorno), [X]candidiasis, no especificada, Infección por Candida NEOM, Infección por Cándida, Cándida NEOM, Candidiasis NEOM, Moniliasis NEOM, Candidiasis de localización no especificada, Monilia NEOM, Infección monilial, candidiasis (trastorno), candidiasis, candidosis, infección por especies de Candida, moniliasis, Infecciones por cándida, Candidiasis, Moniliasis
Italian Infezioni da candida, Moniliasi, Infezione da Candida, Candidiasi / Candida, Candidiasi NAS, Candida NAS, Candidiasi, Candidiasi di sede non specificata, Infezione da Candida NAS, Candidosi
Swedish Kandidos
Czech kandidóza, Kandidové infekce, moniliáza, Kandidy NOS, Kandidóza, Moniliáza, Kandidóza na blíže neurčeném místě, Kandidová infekce, Kandidová infekce NOS, Infekce způsobená Candida, Kandida NOS, Kandidóza NOS, Moniliáza NOS
Finnish Kandidiaasi
Russian KANDIDOZ, MONILIAZ, КАНДИДОЗ, МОНИЛИАЗ
German CANDIDIASIS, Kandidose, nicht naeher bezeichnet, MONILIASIS, Candidiasis unspezifischer Stelle, Candida NNB, Moniliasis NNB, Candidainfektion NNB, Candida-Infektion, Candidiasis NNB, Monilioseinfektion, Moniliasis durch Monilia, Candida-Infektionen, Candida-Mykosen, Candidose, Kandidose, Moniliasis, Soor, Candidiasis
Korean 상세불명의 칸디다증, 칸디다증
Croatian KANDIDIJAZA
Polish Kandidiaza, Zakażenie Candida albicans, Moniliaza, Oidiomikoza, Bielnica, Kandydoza
Hungarian Candida fertőzések, moniliasis k.m.n., Moniliazisos fertőzés, candidiasis, moniliasis, Moniliasis monilia, candidiasis k.m.n., Candida k.m.n., Nem meghatározott elhelyezkedésű candidiasis, Candida fertőzés, Monilia k.m.n., Candidás fertőzés k.m.n.
Japanese カンジダ症, カンジダ感染症, ｶﾝｼﾞﾀﾞｶﾝｾﾝ, ｶﾝｼﾞﾀﾞｼｮｳ, ｶﾝｼﾞﾀﾞｼｮｳNOS, モニリアＮＯＳ, カンジダ感染, カンジダ症ＮＯＳ, モニリア感染, ｶﾝｼﾞﾀﾞNOS, ﾌﾞｲﾌﾒｲﾉｶﾝｼﾞﾀﾞｼｮｳ, カンジダ感染ＮＯＳ, ﾓﾆﾘｱｶﾝｾﾝ, カンジダＮＯＳ, ﾓﾆﾘｱNOS, ｶﾝｼﾞﾀﾞｶﾝｾﾝNOS, ﾓﾆﾘｱｼｮｳ, 部位不明のカンジダ症, モニリア症ＮＯＳ, ﾓﾆﾘｱｼｮｳNOS, モニリア症
Norwegian Candidainfeksjoner, Candidose, Kandidose, Candidiasis, Moniliase, Moniliasis
Dutch Monilia NAO, candidiasis NAO, moniliasis Monilia, moniliasis NAO, Candida-infectie NAO, candidiasis op niet-gespecificeerde plaats, Monilia-infectie, moniliasis, Candida-infectie, candidiasis, Candida NAO, Monilia; infectie, candida; infectie, infectie; Monilia, infectie; candida, Candidiasis, niet gespecificeerd, Candida-infecties, Candidiasis, Moniliasis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Candidiasis of the esophagus (C0239295)

Concepts Disease or Syndrome (T047)
ICD9 112.84
ICD10 B37.81
SnomedCT 20639004, 187023002
English ESOPHAGEAL CANDIDIASIS, Esophageal candidiasis, Esophageal moniliasis, Oesophageal candidiasis, Oesophageal moniliasis, esophageal candidiasis (diagnosis), esophageal candidiasis, Esophageal candida, Oesophageal candida, Candida oesophagitis, Candida of oesophagus, Candidal oesophagitis, candida oesophagitis, Candidiasis;oesophageal, candidas esophageal, esophagitis candida, candida esophagus, candidiasis esophagus, esophageal candida, monilial esophagitis, candida esophagitis, candidal esophagitis, candidiasis esophageal, esophageal thrush, Candida esophagitis, Candidal esophagitis, Candida of esophagus, Candidiasis of esophagus, Candidiasis of oesophagus, Candidosis of esophagus, Candidosis of oesophagus, Esophageal thrush, Oesophageal thrush, Candidiasis of the esophagus, Candidiasis of the oesophagus, Candidiasis of the esophagus (disorder), Candida Esophagitis, Candidiasis;esophageal, oesophageal candidiasis
Italian Candidiasi esofagea, Candidiasi dell'esofago, Esofagite da candida, Candida esofagea, Candida dell'esofago, Candida all'esofago, Esofagite da Candida, Esofagite candidosica
Dutch Candida van slokdarm, candidiasis van de oesofagus, slokdarm spruw, Candida-oesofagitis, Candida-slokdarmontsteking, oesofageale candida, oesofageale Candida, candidiasis van de slokdarm, oesofageale candidiasis, oesofagitis als gevolg van Candida, slokdarmcandidiasis
French Oesophagite à Candida, Candida oesophagien, Candida de l'oesophage, Candidose de l'oesophage, Candidose oesophagienne
German Oesophagussoor, Candida des Oesophagus, oesophageale Candida, Candida als Ursache von Oesophagitis, oesophageale Candidose, Soor im Oesophagus, Oesophagitis durch Candida, Candidose des Oesophagus
Portuguese Candida do esófago, Esofagite por Candida, Candida esofágica, Candidíase do esófago, Esofagite por Cândida, Esogafite por Candida Albicans, Candidíase esofágica
Spanish Candidiasis del esófago, Candidiasis de esófago, Cándida esofágica, Moniliasis esofágica, Muguet esofágico, Esofagitis por cándida, Cándida de esófago, Esofagitis por Cándida, Esófago afectado por Cándida, Esofagitis por Cándida albicans, candidosis esofágica, candidiasis del esófago (trastorno), candidiasis del esófago, candidiasis esofágica, candidiosis esofágica, moniliasis esofágica, Candidiasis esofágica
Japanese 食道カンジダ症, 食道カンジダ, カンジダ性食道炎, ｼｮｸﾄﾞｳｶﾝｼﾞﾀﾞ, ｶﾝｼﾞﾀﾞｾｲｼｮｸﾄﾞｳｴﾝ, ｼｮｸﾄﾞｳｶﾝｼﾞﾀﾞｼｮｳ
Czech Kandidová ezofagitida, Kandidová infekce jícnu, Kandidóza ezofagu, Ezofageální kandidová infekce, Ezofageální kandidóza, Jícnová kandidóza, Kandidóza jícnu, Houba v jícnu, Kvasinková ezofagitida
Hungarian Nyelőcső candidiasis, Candida okozta oesophagitis, Oesophagealis candidiasis, Oesophagealis candida, oesophagealis candidiasis, nyelőcső-candidiasis, Nyelőcső a candidiasisa, Oesophagus candidiasisa, Nyelőcső candida, Oesophagealis penész, Oesophagealis penészfertőzés, Candida által okozott nyelőcsőgyulladás, Nyelőcső Candidiasis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Renal tract candidiasis (C0343882)

Concepts Disease or Syndrome (T047)
SnomedCT 240721007
English candidiasis of renal tract (diagnosis), candidiasis of renal tract, Renal tract candidiasis, Urinary tract candidosis, Renal tract candidiasis (disorder)
Spanish candidiasis de vías urinarias (trastorno), candidiasis de vías urinarias, candidiosis de vías urinarias
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Candiduria (C0403723)

Concepts Finding (T033)
SnomedCT 236721000
Italian Candiduria, Candida urinaria
Dutch urine candida, candidurie
Portuguese Candida na urina, Candiduria
Spanish Cándida en orina, candiduria (trastorno), candiduria, Candiduria
Japanese カンジダ尿, 尿中カンジダ, ｶﾝｼﾞﾀﾞﾆｮｳ, ﾆｮｳﾁｭｳｶﾝｼﾞﾀﾞ
French Candida dans l'urine, Candidurie
Czech Kandida v moči, Kandidurie
English candida urine, candiduria, Urine candida, Candiduria, Candiduria (disorder)
Hungarian candiduria, Vizelet candida
German Candida im Urin
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Pseudomembranous thrush (C0521840)

Concepts Disease or Syndrome (T047)
SnomedCT 95893008
Dutch pseudo-membraan-candidiasis
French Candidose pseudomembraneuse
German pseudomembranoese Candidose
Italian Candidiasi pseudomembranosa
Portuguese Candidíase pseudomembranosa
Spanish Candidiasis pseudomembranosa, muguet pseudomembranoso, muguet seudomembranoso (trastorno), muguet seudomembranoso
Japanese 偽膜性カンジダ症, ｷﾞﾏｸｾｲｶﾝｼﾞﾀﾞｼｮｳ
Czech Pseudomembranózní kandidóza
English pseudomembranous candidiasis, candidiasis pseudomembranous, Pseudomembranous candidiasis, Pseudomembranous thrush, Pseudomembranous thrush (disorder)
Hungarian Pseudomembranosus candidiasis
Derived from the NIH UMLS (Unified Medical Language System)

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