Candidiasis

Aka: Candidiasis, Moniliasis, Urinary Tract Candidiasis, Candiduria

1. See Also
   1. Cutaneous Candidiasis
   2. Candida Diaper Dermatitis
   3. Candida Vulvovaginitis
   4. Thrush
2. Etiology
   1. Candida albicans
3. Risk Factors
   1. Skin maceration
   2. Immunosuppressed patients
      1. Advanced Human Immunodeficiency Virus (AIDS)
      2. Hematologic Malignancy
      3. Antibiotic use
      4. Corticosteroid use
      5. Pregnancy
      6. Diabetes Mellitus
4. Signs: Systemic involvement in immunocompromised patient
   1. Severe muscle tenderness
5. 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
6. Signs: Specific Lesions
   1. Oral Thrush
      1. White Plaques firmly adhered to Oral Mucosa
   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. Gastrointestinal
      1. Distal esophagus ulcerations
   5. Hematogenous (Immunosuppressed)
      1. Fever
      2. Malaise
      3. Retinal abscess
      4. Pulmonary nodular infiltrate
      5. Endocarditis
7. Labs
   1. Abscess drainage shows candida mycelia
   2. Candida Serology titers elevated
   3. KOH Preparation
      1. Pseudohyphae
8. Management: General
   1. Cutaneous
      1. Nystatin
      2. Ciclopirox
      3. Imidazole cream
   2. Oral Thrush
      1. Clotrimazole
         1. One troche dissolve in mouth x5 qd for 7-14 days
      2. Nystatin suspension
         1. Swish and swallow 4-6 times per day for 7-14 days
      3. Fluconazole 100 mg PO qd for 7-14 days
   3. Esophageal
      1. Fluconazole 100-200 mg PO/IV qd for 14-21 days
      2. Amphotericin B 0.3 mg/kg/day for 5-10d
         1. Indicated for severe cases only
      3. Ketoconazole 200-400 mg orally daily for 14-21 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
9. 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 200-400 mg orally or IV once daily for 2-3 days before and after procedure OR
      2. Amphotericin B 0.3 to 0.6 mg/kg once daily for 2-3 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
10. 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