What is the treatment for candidiasis?

Treatment of Candidiasis

The treatment of candidiasis varies by site of infection, with fluconazole being the first-line systemic agent for most forms, while topical azoles are preferred for cutaneous and mild oropharyngeal infections. 1, 2

Oropharyngeal Candidiasis (Thrush)

Treatment by Severity

• Mild disease:

  • Clotrimazole troches, 10 mg 5 times daily for 7-14 days 1, 2
  • Miconazole mucoadhesive buccal 50-mg tablet applied once daily for 7-14 days 1
  • Nystatin suspension (100,000 U/mL) 4-6 mL 4 times daily, or 1-2 nystatin pastilles (200,000 U each) 4 times daily, for 7-14 days 1, 3

• Moderate to severe disease:

  • Oral fluconazole, 100-200 mg daily for 7-14 days 1, 2

• Fluconazole-refractory disease:

  • Itraconazole solution, 200 mg once daily for up to 28 days 1, 4
  • Posaconazole suspension, 400 mg twice daily for 3 days then 400 mg daily 1
  • Voriconazole, 200 mg twice daily 1, 2
  • Amphotericin B oral suspension, 100 mg/mL 4 times daily 1

• Severe refractory cases:

  • Intravenous echinocandin (caspofungin: 70-mg loading dose, then 50 mg daily; micafungin: 100 mg daily; or anidulafungin: 200-mg loading dose, then 100 mg daily) 1, 2
  • Intravenous amphotericin B deoxycholate, 0.3 mg/kg daily 1

Special Considerations

• For denture-related thrush, proper denture hygiene and disinfection are essential in addition to antifungal therapy 2
• For recurrent infections, especially in HIV patients, suppressive therapy with fluconazole 100 mg 3 times weekly is recommended 1, 2

Esophageal Candidiasis

• Systemic therapy is required for effective treatment 1
• Fluconazole, 200-400 mg (3-6 mg/kg) daily for 14-21 days 1
• For fluconazole-resistant cases, itraconazole solution, 200 mg daily 1, 4
• For refractory cases, intravenous amphotericin B (0.3-0.7 mg/kg/day) 1

Vulvovaginal Candidiasis

Uncomplicated Cases

• Topical azoles (clotrimazole, miconazole, etc.) for 1-7 days 1, 5
• Oral fluconazole 150 mg as a single dose 1

Complicated Cases

• Longer duration of topical therapy (7-14 days) or multiple doses of oral fluconazole 1
• For recurrent infections, maintenance fluconazole therapy may be needed 1

Cutaneous Candidiasis

• Topical azole creams (clotrimazole, miconazole, etc.) applied twice daily for 7-14 days 6, 7
• Keeping the affected area dry is crucial for treatment success 6, 7
• For candidal paronychia and onychomycosis, oral itraconazole is recommended 1, 8
• For intertrigo, topical azoles with or without low-potency corticosteroids are effective 7

Invasive Candidiasis

Candidemia

• Echinocandin (caspofungin, micafungin, or anidulafungin) is the preferred initial therapy 1
• Step-down to fluconazole (400-800 mg daily) for susceptible isolates after clinical stability 1
• Remove central venous catheters when feasible 1
• Treat for 2 weeks after documented clearance from bloodstream and resolution of symptoms 1

Candida Meningitis

• Amphotericin B deoxycholate, 1 mg/kg IV daily, or liposomal amphotericin B, 5 mg/kg daily 1
• Step-down to fluconazole for susceptible isolates 1
• Remove infected CNS devices if possible 1
• Continue therapy until all signs, symptoms, and CSF/radiological abnormalities resolve 1

Intra-abdominal Candidiasis

• Source control with appropriate drainage/debridement is essential 1
• Antifungal therapy as for candidemia 1
• Duration determined by adequacy of source control and clinical response 1

Neonatal Candidiasis

• Amphotericin B deoxycholate, 1 mg/kg daily 1
• Fluconazole, 12 mg/kg daily (if no prior fluconazole prophylaxis) 1
• Remove central venous catheters when possible 1
• Perform lumbar puncture and dilated retinal examination 1

Clinical Pearls and Pitfalls

• Diagnosis pitfall: Positive Candida cultures from respiratory secretions usually indicate colonization, not infection, and rarely require treatment 1
• Treatment pitfall: Development of azole resistance is more common in immunocompromised patients with recurrent or prolonged exposure to azoles 2, 9
• Management pitfall: Failure to address underlying predisposing factors (diabetes, immunosuppression, broad-spectrum antibiotics) may lead to treatment failure or recurrence 6, 10
• Duration pitfall: Stopping treatment prematurely when symptoms resolve can lead to relapse; complete the full recommended course 2