Candidiasis: Cause, Risk Factors, Symptoms, Signs, Investigations, Treatment

Candidiasis

Candidiasis Causes, Risk Factors :

Candida albicans can be cultured from the mouth, feces, & vagina.

Cellular immunodeficiency predisposes to mucocutaneous disease.

When no cause found, persistent vaginal or oral candidiasis- consider suspicion for HIV or diabetes.

The risk factors for invasive candidiasis- broad-spectrum antibiotic therapy, prolonged neutropenia, kidney disease, recent abdominal surgery, & presence of intravascular catheters (while providing total parenteral nutrition).

Candidiasis Risk Factors, Symptoms, Signs, Investigations:

Mucosal Candidiasis

Vulvovaginal candidiasis- Erethematous vagina & labia, thick curd like discharge.

Risk factors include pregnancy, uncontrolled diabetes mellitus, broad spectrum antimicrobial treatment, corticosteroid use, and HIV infection.

Symptoms include acute vulvar pruritus, dyspareunia, & burning vaginal discharge.

Candida balanitis- Penile pruritus, & whitish patches on penis.

Esophageal involvement is most frequent.

Symptoms include gastroesophageal reflux, substernal odynophagia, or nausea without substernal pain dysphagia.

Oral candidiasis- Thick white patches on the oral mucosa, burning mouth or tongue, sore & painful mouth.

Diagnosis is best confirmed by- endoscopy with biopsy & culture.

B. Candidal Funguria

symptoms and signs of Candida urinary tract infections- fever, chills, urgency, hesitancy, or flank pain.

C. Invasive Candidiasis

can be

(1) candidemia (bloodstream infection) without deep-seated infection;

(2) candidemia with deep-seated infection (kidney, eyes, or abdomen); and

(3) deep-seated candidiasis in absence of bloodstream infection (hepatosplenic candidiasis).

Clinical presentation from minimal fever to septic shock.

blood cultures positive only 50% in invasive infection.

In high-risk patients positive (1,3)-beta-D-glucan results- may be used to guide empiric therapy even in absence of positive blood cultures.

Hepatosplenic candidiasis can occur in prolonged neutropenia in underlying hematologic cancers..

Blood cultures are generally negative.

D. Candidal Endocarditis

Candidal endocarditis with prosthetic heart valves or prolonged candidemia with indwelling catheters.

Diagnosis- culturing Candida from vegetation at the time of valve replacement.

Candidiasis Treatment:

Mucosal Candidiasis:

Vulvovaginal candidiasis- topical or oral azoles.

T. Fluconazole single 150 mg dose.

Topical-

clotrimazole, 100 mg vaginal tablet- 7 days, or

miconazole, 200 mg vaginal suppository- 3 days.

If disease recurrence, weekly T. fluconazole (150 mg weekly).

Vulvovaginal candidiasis by non albicans strains (eg, Candida glabrata) may require alternative therapies (intravaginal boric acid) in azole resistance.

Esophageal candidiasis:

Patients able to swallow- T. fluconazole 200–400 mg daily for 14–21 days.

Unable to tolerate oral treatment- IV Fluconazole, 400 mg daily, or Echinocandin.

fluconazole-refractory disease- oral itraconazole solution 200 mg daily; or

oral or intravenous voriconazole, 200 mg twice daily; or

or intravenous echinocandin (caspofungin, 70 mg loading dose, & then 50 mg/day; or anidulafungin, 200 mg/day; or intravenous micafungin, 150 mg/day).

T. Posaconazole, 300 mg/day, for fluconazole-refractory disease.

Relapse is common with all the agents if underlying HIV infection without adequate immune reconstitution.

B. Candidal Funguria

resolves with discontinuance of antibiotics & or removal of bladder catheters.

persistent funguria should raise suspicion of invasive infection, & use oral fluconazole, 200 mg/day 7–14 days.

C. Invasive Candidiasis:

IV Echinocandin as first-line therapy

(ie, caspofungin (70 mg once, then 50 mg daily), or micafungin (100 mg daily), or anidulafungin (200 mg once, then 100 mg daily).

IV or T. fluconazole (800 mg once, then 400 mg daily) for less critically ill or without recent azole exposure.

Therapy continue for 2 weeks after last positive blood culture & resolution of symptoms & signs of infection.

A dilated fundoscopic examination for candidemia patients to exclude endophthalmitis.

Susceptibility testing is recommended on all bloodstream Candida isolates; once patients have become clinically stable, parenteral therapy can be discontinued and treatment can be completed with oral fluconazole, 400 mg daily for susceptible isolates.

Removal or exchange of intravascular catheters.

Hepatosplenic candidiasis- treatment until lesions resolved radiographically.

Echinocandin recommended for C glabrata infection with transition to T. fluconazole or voriconazole reserved if isolates susceptible to these agents.

Isolates resistance to azoles & echinocandins, lipid formulation amphotericin B (3–5 mg/kg IV daily).

C krusei is generally fluconazole-resistant- use echinocandin or voriconazole.

Health care–associated infections- multidrug resistant Candida auris- treated with echinocandins plus control of environmental source.

D. Candidal Endocarditis:

medical & surgical therapy (valve replacement).

Lipid formulation amphotericin B (3–5 mg/kg/day) or

high dose echinocandin (caspofungin 150 mg/day, or micafungin 150 mg/day, or anidulafungin 200 mg/day) as initial therapy.

Step-down or long-term suppressive therapy in nonsurgical candidates- fluconazole at 6–12 mg/kg/day if susceptible organisms.

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