What is the treatment for Candida albicans infections?

Treatment of Candida albicans Infections

For Candida albicans infections, fluconazole is the preferred first-line therapy across most clinical scenarios, with dosing and duration dependent on infection site and severity. 1

Treatment by Clinical Syndrome

Invasive Candidiasis and Candidemia

For invasive C. albicans infections, fluconazole 400 mg daily (6 mg/kg) is appropriate first-line therapy in non-critically ill patients with documented susceptible isolates. 1

• In critically ill patients, initiate treatment with an echinocandin (caspofungin, micafungin, or anidulafungin) rather than fluconazole, then de-escalate to fluconazole once the patient stabilizes and susceptibility is confirmed 1
• Continue treatment for at least 14 days after documented clearance of Candida from bloodstream and resolution of symptoms 1, 2
• Remove all central venous catheters whenever feasible, as this significantly improves outcomes 1, 2
• For intra-abdominal candidiasis with documented C. albicans, fluconazole is appropriate if the isolate is susceptible 1

Esophageal Candidiasis

Treat esophageal candidiasis with fluconazole 100 mg daily (or up to 200 mg daily for more severe cases) for 14-21 days. 1

• Fluconazole and itraconazole solution (200 mg/day) are both highly effective, though fluconazole is preferred due to superior tolerability 1
• Endoscopy is not required before initiating treatment in most cases, but consider it if symptoms persist despite therapy to evaluate for alternative diagnoses 1
• For fluconazole-refractory disease, escalate to itraconazole solution at doses >200 mg/day, or use intravenous amphotericin B (0.3-0.7 mg/kg/day) as salvage therapy 1

Vulvovaginal Candidiasis (VVC)

For uncomplicated vulvovaginal candidiasis, a single dose of oral fluconazole 150 mg is as effective as topical azole therapy. 1

• Uncomplicated VVC (90% of cases) responds to short-course therapy: either single-dose oral fluconazole 150 mg or topical azoles (clotrimazole, miconazole, terconazole) for 1-7 days 1
• Complicated VVC (severe symptoms, non-albicans species, recurrent infections, pregnancy, immunocompromise) requires extended therapy for >7 days 1
• For recurrent VVC (≥4 episodes per year), use induction therapy with 2 weeks of topical or oral azole, followed by maintenance fluconazole 150 mg weekly for 6 months 1
• Critical caveat: Only topical azole therapy should be used in pregnancy—oral fluconazole is associated with spontaneous abortion and should be avoided 1
• Maintenance fluconazole improves quality of life in 96% of women with recurrent VVC, though recurrence after stopping prophylaxis occurs in >63% of cases 1

Central Nervous System Infections

For CNS candidiasis, initiate liposomal amphotericin B 5 mg/kg daily, with or without oral flucytosine 25 mg/kg four times daily. 1

• Liposomal amphotericin B achieves higher brain concentrations than other amphotericin formulations 1
• Add flucytosine for synergistic activity and excellent CSF penetration, but monitor serum levels, liver function, and bone marrow closely due to toxicity 1
• After several weeks of amphotericin-based therapy, transition to oral fluconazole for step-down therapy once clinical improvement is documented 1
• Continue treatment for an extended duration (weeks to months) based on clinical and radiographic response 1

Candida Endophthalmitis

For chorioretinitis without vitritis, use fluconazole 400-800 mg daily (6-12 mg/kg) or liposomal amphotericin B 3-5 mg/kg daily, with ophthalmology consultation. 1

• When vitritis is present, add intravitreal injection of amphotericin B deoxycholate or voriconazole to achieve high posterior chamber drug concentrations 1
• Consider early pars plana vitrectomy for vitritis, as this decreases the risk of retinal detachment and improves outcomes 1
• Close collaboration between infectious diseases and ophthalmology is essential for optimal management 1

Special Populations

Neonates and Pediatric Patients

In neonates with disseminated candidiasis, fluconazole 12 mg/kg daily is recommended if C. albicans is isolated. 1, 2

• Fluconazole is well-tolerated and a major prophylactic drug for high-risk neonates 3
• For empiric therapy when Candida is suspected in neonates, start antifungal treatment immediately 1
• Echinocandins should generally be limited to salvage therapy in neonates 2

Neutropenic Patients

Fluconazole 400 mg daily is appropriate for prophylaxis during neutropenia in high-risk patients (allogeneic bone marrow transplant, acute myelogenous leukemia). 1

• For treatment of documented C. albicans infection in neutropenic adults, fluconazole is acceptable as long as the isolate is susceptible 3
• Local epidemiology and prior antifungal exposure should guide empiric therapy choices 1

HIV/AIDS Patients

Prophylactic fluconazole should be limited to HIV-positive patients in virologic-immunologic failure with recurrent mucosal candidiasis. 3

• Avoid routine prophylaxis to minimize emergence of azole-resistant strains 3
• For fluconazole-refractory oral candidiasis in AIDS patients, itraconazole solution is effective second-line therapy 1

Dosing Considerations

Standard fluconazole dosing for invasive infections is 400 mg (6 mg/kg) daily, but increase to 800 mg (12 mg/kg) daily for severe infections or to ensure adequate drug levels. 1, 2

• Fluconazole exhibits predictable pharmacokinetics with excellent oral bioavailability 4, 3
• No dose adjustment needed for obesity, but consider higher doses in critically ill patients with augmented renal clearance 1
• Reduce dose in renal impairment based on creatinine clearance 1

Common Pitfalls and Caveats

Do not assume all Candida species have similar susceptibility—C. krusei is intrinsically resistant to fluconazole, and C. glabrata often shows reduced susceptibility. 3, 2

• Always obtain cultures and susceptibility testing before finalizing therapy 1
• Antifungal susceptibility testing at vaginal pH 4 (rather than laboratory standard pH 7) reveals clinically relevant resistance that may contribute to treatment failure 1
• Alternative treatments for VVC (honey-based ointments, essential oils, herbal preparations) are equal or inferior to FDA-approved medications and are not recommended 1
• Amphotericin B should not be used as initial therapy for most C. albicans infections due to toxicity, except for CNS infections where it remains first-line 1
• Echinocandins (micafungin, caspofungin, anidulafungin) are preferred over fluconazole in critically ill patients and those with prior azole exposure 1, 5

Duration of Therapy

Treat candidemia for at least 14 days after blood culture clearance and symptom resolution; deep-seated infections require longer courses until all clinical, laboratory, and radiographic abnormalities resolve. 1, 2

• For esophageal candidiasis: 14-21 days 1
• For uncomplicated VVC: single dose or 1-7 days 1
• For complicated VVC: >7 days 1
• For recurrent VVC maintenance: 6 months 1
• For CNS infections: weeks to months based on response 1