What is the treatment for candidiasis?

Treatment of Candidiasis

Treatment of candidiasis depends entirely on the anatomical site and severity of infection, with topical azoles for superficial infections and systemic antifungals for invasive disease.

Invasive Candidiasis and Candidemia

Initial Treatment

• For candidemia without metastatic complications, echinocandins are the preferred first-line agents (though not explicitly stated in the provided guidelines, amphotericin B deoxycholate 1 mg/kg IV daily or liposomal amphotericin B 5 mg/kg daily are recommended alternatives) 1
• Continue treatment for 2 weeks after documented clearance of Candida from bloodstream and resolution of attributable signs 1

Step-Down Therapy

• Transition to fluconazole 12 mg/kg daily (approximately 400-800 mg daily) for isolates susceptible to fluconazole once the patient is clinically stable 1
• This step-down approach applies after initial response to amphotericin B therapy 1

Source Control

• For intra-abdominal candidiasis, source control with drainage and/or debridement is mandatory alongside antifungal therapy 1
• Treatment duration depends on adequacy of source control and clinical response 1

Oropharyngeal and Esophageal Candidiasis

Oropharyngeal Candidiasis

• Fluconazole 100-200 mg daily orally for 7-14 days is first-line treatment 2, 3
• Itraconazole oral solution 200 mg daily for 14-21 days is equally effective but less well-tolerated 2, 3
• For fluconazole-refractory cases, use itraconazole solution 100 mg twice daily 3
• Clinical response typically occurs within 48-72 hours, though the full course must be completed 2

Esophageal Candidiasis

• Fluconazole 100 mg daily orally for 14-21 days is the treatment of choice 2
• Itraconazole solution 100 mg daily (minimum 3 weeks, continue 2 weeks after symptom resolution) is an alternative 2, 3
• For refractory disease: escalate to itraconazole >200 mg/day, or use IV amphotericin B 0.3-0.7 mg/kg/day, or echinocandins (caspofungin, micafungin, anidulafungin) 2
• Definitive diagnosis requires endoscopy with histopathology and culture 2

Important Considerations

• The oral solution formulation must be vigorously swished in the mouth before swallowing for oropharyngeal disease 3
• Itraconazole oral solution and capsules are not interchangeable; only the solution is effective for oral/esophageal candidiasis 3
• Relapse rates are high (all patients within 1 month in one study) when treatment is discontinued prematurely 3

Cutaneous and Mucocutaneous Candidiasis

Cutaneous Candidiasis (Including Inguinal)

• Apply topical azoles (clotrimazole 1% or miconazole 2% cream) twice daily for 7-14 days 4, 5
• Nystatin cream or ointment is an alternative topical option 4
• Keeping the affected area dry is critically important, especially in obese and diabetic patients 4, 5
• If topical therapy fails after 2 weeks, switch to oral fluconazole 150-200 mg daily for 7-14 days 5

Special Populations

• Healthy term neonates with disseminated cutaneous candidiasis require only topical therapy 5
• Premature or low-birth weight neonates must receive systemic amphotericin B 0.5-1 mg/kg/day (total dose 10-25 mg/kg) to prevent lethal invasive disease 5
• Neutropenic or severely immunocompromised patients with cutaneous candidiasis may have disseminated disease and require aggressive systemic therapy with an echinocandin 5

Non-albicans Species

• For azole-resistant non-albicans species (C. glabrata, C. krusei), consider topical boric acid or topical flucytosine 5

Vulvovaginal Candidiasis

Uncomplicated Cases

• Short-course oral or topical azole therapy is highly effective (single-dose regimens acceptable) 1
• Topical options include clotrimazole, miconazole, or nystatin for 1-7 days 1
• Oral fluconazole 150 mg as a single dose is equally effective 6

Complicated Cases

• Requires antimycotic therapy for >7 days 1
• Non-albicans species respond to topical boric acid 600 mg daily for 14 days or topical flucytosine 1

Recurrent Vulvovaginal Candidiasis

• After controlling causal factors (uncontrolled diabetes), give 2 weeks of induction therapy with topical or oral azole 1
• Follow with 6-month maintenance regimen: fluconazole 150 mg weekly, ketoconazole 100 mg daily, itraconazole 100 mg every other day, or daily topical azole 1
• Long-term fluconazole prophylaxis is effective but should be reserved for frequent or debilitating recurrences to minimize resistance development 2, 7

Cardiac and CNS Candidiasis

Endocarditis

• Lipid formulation amphotericin B 3-5 mg/kg daily (with or without flucytosine 25 mg/kg four times daily) OR high-dose echinocandin (caspofungin 150 mg, micafungin 150 mg, or anidulafungin 200 mg daily) 1
• Valve replacement is mandatory; continue antifungals for at least 6 weeks post-surgery 1
• Step-down to fluconazole 400-800 mg daily for susceptible isolates after clinical stability and bloodstream clearance 1
• Patients unable to undergo valve replacement require lifelong fluconazole suppression 400-800 mg daily 1

CNS Candidiasis

• Amphotericin B deoxycholate 1 mg/kg IV daily or liposomal amphotericin B 5 mg/kg daily 1
• Consider adding flucytosine 25 mg/kg four times daily for salvage therapy in non-responders (though adverse effects are frequent) 1
• Remove infected CNS devices (ventriculostomy drains, shunts) whenever possible 1
• Continue therapy until all signs, symptoms, CSF abnormalities, and radiological findings resolve 1

Urinary Candidiasis

• Most candiduria represents benign colonization, not infection 1
• Removing or changing Foley catheters alone clears candiduria in approximately 40% of patients 1
• For true urinary tract infection: fluconazole (oral or IV), amphotericin B (IV), or flucytosine (oral) 1
• Amphotericin B bladder irrigation only treats disease at the bladder level, not upper tract infection 1

Pulmonary Candidiasis

• Candida isolated from respiratory secretions almost always represents colonization and rarely requires antifungal therapy 1
• True Candida pneumonia is exceedingly rare and requires histopathological confirmation 1
• When proven, treat with IV amphotericin B or oral/IV fluconazole 1

Prophylaxis in High-Risk Populations

Neutropenic Patients

• Fluconazole 400 mg daily during neutropenia for patients at significant risk: acute myelogenous leukemia, allogeneic bone marrow transplant, high-risk autologous transplant 1
• Risk assessment should be based on local experience with specific chemotherapy protocols 1

Solid Organ Transplant

• High-risk liver transplant recipients should receive prophylactic antifungals in the early postoperative period 1
• Fluconazole 400 mg daily for 7 days post-transplant reduces intra-abdominal fungal infections from 10% to 6% 1
• Other solid organ transplants have insufficient risk to warrant routine prophylaxis 1

Neonates

• In nurseries with invasive candidiasis rates >10%, use fluconazole prophylaxis 3-6 mg/kg twice weekly (IV or oral) 1

Critical Pitfalls to Avoid

• Do not confuse inguinal candidiasis with vulvovaginal candidiasis—they require different treatment approaches 4
• Never diagnose Candida pneumonia based solely on respiratory cultures; histopathology is required 1
• Avoid high-potency topical corticosteroids for extended periods as they cause skin atrophy and worsen fungal infections 5
• Do not use occlusive ointments that trap moisture in cutaneous infections 5
• Premature discontinuation of therapy for chronic disseminated candidiasis leads to recurrence, especially in immunosuppressed patients 1
• Injudicious prophylaxis in low-risk populations selects for resistant organisms 1