Candidiasis

Aka: Candidiasis, Candidemia, Moniliasis, Urinary Tract Candidiasis, Candiduria, Esophageal Candidiasis, Pseudomembranous Candidiasis, Candida albicans

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II. Pathophysiology

  1. Candida albicans
    1. Unicellular budding Fungus
    2. Diploid Fungus (contains a full set of DNA from each parent)
      1. Contrast with haploid cells (only 1 set of DNA from each parent)

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: Mucocutaneous Candida

  1. See Candida Diaper Dermatitis
  2. See Candida Vulvovaginitis
  3. General Distribution in Non-Immunocompromised Patients
    1. Mouth
    2. Vagina
    3. Axillae
    4. Inguinal folds
    5. Interdigital surfaces
  4. 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
  5. Cutaneous Candidiasis
    1. Red, macerated intertriginous areas
    2. Erythematous Papules
    3. Pruritic, eroded areas
    4. Scaling and crusting of lesions
  6. 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

V. Signs: Systemic Involvement (Immunocompromised patient)

  1. Findings include mucocutaneous Candidiasis (see above)
  2. Esophageal Candidiasis
    1. Extension of oral Thrush
    2. Distal Esophagus ulcerations
    3. Associated with Dysphagia, odynaphagia and substernal pain
  3. Hematogenous, Disseminated (Candidemia, Immunosuppressed)
    1. Fever
    2. Malaise
    3. Retinal abscess
    4. Pulmonary nodular infiltrate
    5. Endocarditis
    6. Severe Muscle tenderness

VI. Labs

  1. Abscess drainage shows candida mycelia
  2. Candida Serology titers elevated
  3. Blood Cultures
    1. Test Sensitivity <50%
    2. Candida cultured from blood is never normal (disseminated candida, and NOT a contaminant)
    3. However, candida is a contaminant found in urine, Sputum or Stool Cultures
  4. KOH Preparation
    1. Pseudohyphae
  5. Blood Beta-D-Glucan (BDG)
    1. Beta-D-Glucan is a fungal cell wall component and may be present in systemic candida infection

VII. Management: General

  1. Cutaneous
    1. Nystatin
    2. Ciclopirox
    3. Imidazole cream
  2. Oral Thrush
    1. See Oral Thrush
    2. Fluconazole 100 mg orally daily for 7 to 14 days
      1. Preferred first-line option
    3. Clotrimazole Troches
      1. One troche dissolve in mouth 5 times daily for 7 to 14 days
    4. Nystatin suspension
      1. Swish and swallow 4 to 6 times per day for 7 to 14 days
  3. Esophageal
    1. Fluconazole 3-6 mg/kg up to 200 to 400 mg oral or IV daily for 14 to 21 days
    2. Alternative: Azoles
      1. Intraconazole 200 mg/day orally for 14 to 21 days
      2. Voriconazole 200 mg orally twice daily for 14 to 21 days
      3. Posaconazole
      4. Isavuconazole 372 mg orally or IV every 8 hours for 6 doses, then 372 mg orally/IV daily
    3. Alternative: Echinocandin (Cyclic Lipopeptide)
      1. Caspofungin
      2. Micafungin
      3. Anidulafungin
    4. Other agents with higher toxicity
      1. Amphotericin B 0.5 mg/kg/day (or Liposomal 3-5 mg/kg/day) for 14 to 21 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
    5. 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
    6. References
      1. Schwartz (2024) Sanford Guide, accessed on IOS, 4/8/2025
      2. Mohamed (2019) Can J Gastroenterol Hepatol +PMID: 31772927 [PubMed]

VIII. 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. Cystitis 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. Cystitis 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. Pyelonephritis
      1. Treat as disseminated disease as below
  4. References
    1. Schwartz (2023) Sanford Guide, accessed on IOS, 4/8/2025
    2. Odabasi (2020) World J Urol 38(11):2699-707 +PMID: 31654220 [PubMed]
    3. 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

IX. Management: Disseminated Candidiasis (Candidemia)

  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
    4. Rezafungin 400 mg IV load, then 200 mg IV once weekly
  2. Known Candida albicans or Candida parapsilosis or Candida tropicalis (or clinically stable with negative cultures)
    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. Schwartz (2024) Sanford Guide, accessed on IOS, 4/8/2025

X. Resources

  1. Candidiasis (Stat Pearls)
    1. https://www.ncbi.nlm.nih.gov/books/NBK560624/

XI. References

  1. Parker and Bond (2023) Crit Dec Emerg Med 37(10): 4-9
  2. Pappas (2016) Clin Infect Dis 62(4):e1-50 +PMID: 26679628 [PubMed]

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