What is the management for candidiasis?

Management of Candidiasis

Management of candidiasis is site-specific and depends on disease severity, with oral fluconazole being the preferred systemic agent for most forms, while topical therapy suffices for mild mucocutaneous disease. 1

Oropharyngeal Candidiasis

Mild Disease

• Clotrimazole troches 10 mg 5 times daily for 7-14 days is first-line treatment 1, 2
• Miconazole mucoadhesive buccal 50-mg tablet applied once daily over the canine fossa for 7-14 days is equally effective 1, 2
• Alternative options include nystatin suspension (100,000 U/mL) 4-6 mL 4 times daily or nystatin pastilles (200,000 U each) 4 times daily for 7-14 days 1

Moderate to Severe Disease

• Oral fluconazole 100-200 mg daily for 7-14 days is the treatment of choice 1, 2
• This represents a step-up from topical therapy when symptoms are more severe or extensive 1

Fluconazole-Refractory Disease

• Itraconazole solution 200 mg once daily for up to 28 days is first-line for refractory cases 1, 2, 3
• Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days is an alternative 1, 2
• Voriconazole 200 mg twice daily or amphotericin B deoxycholate oral suspension 100 mg/mL 4 times daily can be used 1
• For severe refractory cases, intravenous echinocandins (caspofungin 70-mg loading dose then 50 mg daily; micafungin 100 mg daily; or anidulafungin 200-mg loading dose then 100 mg daily) or IV amphotericin B deoxycholate 0.3 mg/kg daily 1, 2

Special Considerations for Oral Candidiasis

• Denture disinfection is mandatory in denture-related candidiasis alongside antifungal therapy 2
• HIV-infected patients require antiretroviral therapy to reduce recurrence 1, 2
• Chronic suppressive therapy with fluconazole 100 mg three times weekly may be needed for recurrent infections 1, 2

Critical pitfall: Completing the full 7-14 day course is essential even after symptom resolution to prevent relapse 2

Vulvovaginal Candidiasis

Uncomplicated Disease

• Topical antifungal agents are first-line, with no single agent demonstrating superiority 1
• Oral fluconazole 150 mg single dose achieves 55% therapeutic cure rate (clinical cure plus mycologic eradication) comparable to 7-day intravaginal therapy 4
• Single-dose fluconazole is particularly convenient but causes more gastrointestinal side effects (16% vs 4%) compared to vaginal products 4

Recurrent Vulvovaginitis

• Patients with ≥4 episodes per 12 months achieve lower cure rates (40% therapeutic cure with fluconazole 150 mg) 4
• These patients require more intensive or prolonged therapy regimens 4

Urinary Tract Candidiasis

Cystitis (Fluconazole-Susceptible)

• Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks 1
• Removal of indwelling bladder catheter is strongly recommended if feasible 1

Cystitis (Fluconazole-Resistant Species)

• For C. glabrata: amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days OR oral flucytosine 25 mg/kg 4 times daily for 7-10 days 1
• For C. krusei: amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1
• Amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) may be useful for fluconazole-resistant species 1

Pyelonephritis (Fluconazole-Susceptible)

• Oral fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks 1
• Elimination of urinary tract obstruction is mandatory 1
• Consider removal or replacement of nephrostomy tubes or stents if present 1

Pyelonephritis (Fluconazole-Resistant)

• For C. glabrata: amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days with or without flucytosine 25 mg/kg 4 times daily 1
• Monotherapy with flucytosine 25 mg/kg 4 times daily for 2 weeks can be considered 1

Fungal Balls/Bezoars

• Surgical intervention is strongly recommended 1
• Antifungal treatment as per cystitis or pyelonephritis protocols 1
• Irrigation through nephrostomy tubes with amphotericin B deoxycholate 25-50 mg in 200-500 mL sterile water 1

Candidemia and Invasive Candidiasis

Nonneutropenic ICU Patients

• Empiric therapy should be initiated in critically ill patients with risk factors (recent abdominal surgery, anastomotic leaks, necrotizing pancreatitis, central lines) and no other fever source 1
• Fluconazole 800-mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) daily in ICUs with >5% invasive candidiasis rate 1
• Echinocandins are an alternative: caspofungin 70-mg loading dose then 50 mg daily; anidulafungin 200-mg loading dose then 100 mg daily; or micafungin 100 mg daily 1
• Central venous catheter removal is strongly recommended 1
• Duration: 2 weeks after documented clearance from bloodstream and resolution of symptoms 1

Neonatal Disseminated Candidiasis

• Amphotericin B deoxycholate 1 mg/kg daily is first-line 1
• Fluconazole 12 mg/kg IV or oral daily is reasonable in patients not on fluconazole prophylaxis 1
• Lipid formulation amphotericin B 3-5 mg/kg daily is an alternative but use cautiously with urinary tract involvement 1
• Echinocandins should be limited to salvage therapy in neonates 1
• Lumbar puncture and dilated retinal examination are mandatory in neonates with positive Candida cultures 1
• CT or ultrasound imaging of genitourinary tract, liver, and spleen if blood cultures remain persistently positive 1

CNS Candidiasis

Initial Treatment

• Amphotericin B deoxycholate 1 mg/kg IV daily 1
• Liposomal amphotericin B 5 mg/kg daily is an alternative 1
• Flucytosine 25 mg/kg 4 times daily may be added as salvage therapy for non-responders, though adverse effects are frequent 1

Step-Down Therapy

• Fluconazole 12 mg/kg daily for susceptible isolates after initial response 1
• Continue until all signs, symptoms, CSF abnormalities, and radiological findings resolve 1
• Infected CNS devices (ventriculostomy drains, shunts) must be removed if possible 1

Intra-Abdominal Candidiasis

• Source control with drainage and/or debridement is mandatory 1
• Antifungal choice is the same as for candidemia or empiric ICU therapy 1
• Duration determined by adequacy of source control and clinical response 1

Endocarditis

• Lipid formulation amphotericin B 3-5 mg/kg daily with or without flucytosine 25 mg/kg 4 times daily OR high-dose echinocandin (caspofungin 150 mg daily, micafungin 150 mg daily, or anidulafungin 200 mg daily) for initial therapy 1
• Step-down to fluconazole 400-800 mg (6-12 mg/kg) daily for susceptible isolates after clinical stability and bloodstream clearance 1
• Valve replacement is recommended 1

Chronic Disseminated Candidiasis

• Lipid formulation amphotericin B 3-5 mg/kg daily OR echinocandin for several weeks initially 1
• Followed by oral fluconazole 400 mg (6 mg/kg) daily for patients unlikely to have fluconazole-resistant isolates 1
• Continue until lesions resolve on repeat imaging (usually several months) 1
• Premature discontinuation leads to relapse 1
• Continue antifungal therapy throughout chemotherapy or transplantation if required 1

Prophylaxis Considerations

• Fluconazole prophylaxis 800-mg loading dose then 400 mg daily in high-risk adult ICU patients in units with >5% invasive candidiasis 1
• Daily chlorhexidine bathing in ICU patients may decrease candidemia incidence 1
• In neonatal nurseries with >10% invasive candidiasis rate, fluconazole prophylaxis 3-6 mg/kg twice weekly 1

Critical pitfall: Candida growth from respiratory secretions usually indicates colonization and rarely requires antifungal treatment 1