What is the treatment for candidiasis?

Treatment for Candidiasis

The treatment for candidiasis depends entirely on the anatomic site and severity of infection, with oral fluconazole 150 mg single dose or topical azoles for vulvovaginal disease, oral fluconazole 100-200 mg daily for oropharyngeal disease, and echinocandins for invasive disease being the preferred first-line therapies. 1, 2

Vulvovaginal Candidiasis

For uncomplicated vulvovaginal candidiasis, either a single oral dose of fluconazole 150 mg or topical azole antifungals (clotrimazole, miconazole) applied intravaginally for 1-7 days are equally effective first-line options. 3, 2

• Oral fluconazole achieves 92-99% clinical cure rates at short-term evaluation (5 days post-treatment) and 88-91% efficacy at long-term follow-up (80-100 days). 3, 4
• No single topical azole is superior to another; choice is based on patient preference and convenience. 2
• For recurrent vulvovaginal candidiasis (≥4 episodes per year), treat the acute episode with fluconazole 150 mg single dose, then initiate maintenance therapy with fluconazole 150 mg weekly for 6 months. 3

Oropharyngeal Candidiasis (Thrush)

Oral fluconazole 100-200 mg daily for 7-14 days is the preferred initial treatment for oropharyngeal candidiasis. 5, 2

• Alternative topical options include clotrimazole troches 10 mg five times daily for 7-14 days or nystatin suspension 100,000 U/mL (4-6 mL four times daily) for 7-14 days. 5, 6
• Topical agents are appropriate for mild disease, but systemic therapy is preferred for moderate to severe disease. 2
• Critical pitfall: Avoid ketoconazole or itraconazole capsules due to variable absorption and inferior efficacy compared to fluconazole. 5

Esophageal Candidiasis

Systemic therapy is mandatory for esophageal candidiasis; fluconazole 200-400 mg daily orally for a minimum of 14 days and at least 7 days following resolution of symptoms is the preferred treatment. 1, 2, 7

• Topical treatment is completely ineffective for esophageal disease. 5
• Alternative agents for refractory cases include itraconazole oral solution 200 mg daily, posaconazole 400 mg twice daily, or an echinocandin. 1

Candidemia and Invasive Candidiasis

Echinocandins (caspofungin loading dose 70 mg then 50 mg daily, micafungin 100 mg daily, or anidulafungin loading dose 200 mg then 100 mg daily) are the preferred first-line agents for most patients with candidemia. 1, 2

• Fluconazole (loading dose 800 mg, then 400 mg daily) is acceptable only for patients who are hemodynamically stable, have mild to moderate illness, and have no recent azole exposure. 1, 2
• Liposomal amphotericin B (3-5 mg/kg daily) is an alternative if there is intolerance to other antifungals. 1
• Treat for 2 weeks after documented clearance of Candida from the bloodstream and resolution of symptoms. 1
• Intravenous catheter removal is strongly recommended for nonneutropenic patients. 1

Species-Specific Considerations

• For C. glabrata: An echinocandin is preferred; liposomal amphotericin B is an alternative. 1
• For C. parapsilosis: Fluconazole or liposomal amphotericin B is preferred over echinocandins due to decreased echinocandin activity. 1, 2
• For C. krusei: An echinocandin, liposomal amphotericin B, or voriconazole is recommended; avoid fluconazole due to intrinsic resistance. 1, 2

Urinary Tract Candidiasis

For symptomatic cystitis due to fluconazole-susceptible organisms, oral fluconazole 200 mg daily for 2 weeks is recommended. 2

• Removal of indwelling bladder catheter is strongly recommended if feasible. 2
• Critical pitfall: Asymptomatic candiduria in males does not require treatment unless the patient is neutropenic or undergoing urologic procedures. 3, 5

Cutaneous and Genital Candidiasis in Males

Topical azole antifungals applied to the affected area 1-2 times daily for 7-14 days are the first-line treatment for male genital candidiasis (balanitis). 5

• Oral fluconazole 150 mg as a single dose is equally effective and may be preferred for convenience. 5
• For cutaneous candidiasis (skin folds, intertrigo), apply topical azoles or polyenes 1-2 times daily for 7-14 days, and keeping the area dry is as essential as the antifungal medication itself. 5

Neonatal Disseminated Candidiasis

Amphotericin B deoxycholate 1 mg/kg daily is the primary treatment for neonatal disseminated candidiasis, with therapy continuing for at least 3 weeks. 1, 2

• Fluconazole 12 mg/kg IV or oral daily is a reasonable alternative in patients not on fluconazole prophylaxis, but liposomal amphotericin B should only be used if there is no renal involvement. 1, 2
• A lumbar puncture and dilated retinal examination should be performed on all neonates with suspected invasive candidiasis. 1
• Intravascular catheter removal is strongly recommended. 1

Central Nervous System Candidiasis

Liposomal amphotericin B 3-5 mg/kg daily with or without flucytosine 25 mg/kg four times daily is recommended for CNS candidiasis. 1

• Treat until all signs, symptoms, CSF abnormalities, and radiological abnormalities have resolved. 1
• Infected CNS devices (ventriculostomy drains, shunts) should be removed if at all possible. 1

Candida Endocarditis

Liposomal amphotericin B 3-5 mg/kg daily with or without flucytosine 25 mg/kg four times daily, or high-dose echinocandin (caspofungin 150 mg daily, micafungin 150 mg daily, or anidulafungin 200 mg daily) is recommended for initial therapy. 1

• Valve replacement is strongly recommended; treatment should continue for at least 6 weeks after surgery. 1
• Step-down therapy to fluconazole 400-800 mg daily is recommended for patients with susceptible isolates who are clinically stable and have cleared Candida from the bloodstream. 1

Intra-Abdominal Candidiasis

Empiric antifungal therapy should be considered for patients with clinical evidence of intra-abdominal infection and significant risk factors (recent abdominal surgery, anastomotic leaks, necrotizing pancreatitis). 1

• Treatment requires source control with appropriate drainage and/or debridement. 1
• The choice of antifungal therapy is the same as for candidemia. 1

Critical Pitfalls to Avoid

• Never treat asymptomatic colonization; treatment should be based on clinical symptoms, not just positive cultures. 5
• Avoid azole therapy in patients with recent azole exposure or prophylaxis due to increased resistance risk. 1, 3
• Growth of Candida from respiratory secretions usually indicates colonization and rarely requires antifungal therapy. 1
• For immunocompromised patients, consider longer treatment courses (14-21 days minimum) and suppressive therapy may be necessary for frequent recurrences. 5