What are the alternative treatment options for candidiasis in a 10-month-old infant that is not responding to Nystatin (nystatin)?

From the Guidelines

For a 10-month-old with candidiasis not responding to nystatin, fluconazole, 12 mg/kg intravenous or oral daily, is a reasonable alternative treatment option. This recommendation is based on the 2016 update by the Infectious Diseases Society of America, which provides a strong recommendation with moderate-quality evidence 1. The use of fluconazole is supported due to its ability to inhibit ergosterol synthesis in the fungal cell membrane, disrupting cell integrity and providing a systemic antifungal effect.

When considering treatment options, it's essential to note the following:

• AmB deoxycholate, 1 mg/kg daily, is recommended for neonates with disseminated candidiasis, but its use in a 10-month-old may not be necessary unless the infection is severe or disseminated 1.
• Lipid formulation AmB, 3–5 mg/kg daily, is an alternative, but should be used with caution, particularly in the presence of urinary tract involvement 1.
• Echinocandins should be used with caution and generally limited to salvage therapy or to situations in which resistance or toxicity preclude the use of AmB deoxycholate or fluconazole 1.

In addition to antifungal treatment, it's crucial to:

• Ensure proper hygiene and cleaning of the affected area to prevent the spread of infection
• Keep the area dry, especially in cases of diaper rash candidiasis
• Consider adding a barrier cream containing zinc oxide after the antifungal treatment
• Monitor the child's response to treatment and adjust as necessary, with further evaluation needed if symptoms persist.

From the FDA Drug Label

Pediatric Studies Oropharyngeal candidiasis: An open-label, comparative study of the efficacy and safety of fluconazole (2 to 3 mg/kg/day) and oral nystatin (400,000 I. U. 4 times daily) in immunocompromised children with oropharyngeal candidiasis was conducted. Clinical and mycological response rates were higher in the children treated with fluconazole.

Clinical cure at the end of treatment was reported for 86% of fluconazole-treated patients compared to 46% of nystatin treated patients

Mycologically, 76% of fluconazole treated patients had the infecting organism eradicated compared to 11% for nystatin treated patients.

For a 10-month-old patient with candidiasis not responding to nystatin, fluconazole may be considered as an alternative treatment option. The dosage for pediatric patients is 2 to 3 mg/kg/day. However, it is essential to note that efficacy of fluconazole has not been established in infants less than 6 months of age, and this patient is close to that age limit. Therefore, caution and close monitoring are advised when using fluconazole in this age group 2.

From the Research

Treatment Options for Candidiasis

• For a 10-month-old patient not responding to nystatin, alternative treatment options can be considered based on the susceptibility of Candida species to various antifungal agents 3, 4, 5, 6, 7.
• The study by 3 found that Candida species showed low resistance to nystatin, making it a suitable choice for oral candidiasis and diaper dermatitis.
• However, if the patient is not responding to nystatin, other antifungal agents such as fluconazole, itraconazole, and voriconazole can be considered 5, 7.
• The study by 5 found that fluconazole, itraconazole, and voriconazole showed fungistatic activity against Candida albicans, with maximum inhibition occurring after 12 hours of antifungal exposure.
• Amphotericin B is also an effective antifungal agent, with no resistance observed in the study by 3.
• The study by 6 highlights the importance of early diagnosis and treatment of invasive candidiasis in infants and children, and suggests the use of liposomal amphotericin B and micafungin as treatment options.

Antifungal Susceptibility

• The study by 7 found that oral Candida isolates had a high level of susceptibility to a range of antifungal agents, including fluconazole, itraconazole, voriconazole, ketoconazole, miconazole, and amphotericin B.
• The study by 3 found that the resistance of Candida species to different antifungal agents was as follows: nystatin (4%), itraconazole (43%), fluconazole (34.2%), ketoconazole (34.9%), clotrimazole (21.5%), voriconazole (6%), and posaconazole (6.7%).
• The study by 5 found that fluconazole, itraconazole, and voriconazole were effective in inhibiting the growth of Candida albicans, with significant differences between the antifungal group and the control group at 12,24, and 48 hours.