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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