What is the treatment for candidiasis?

Treatment for Candidiasis

Treatment Selection by Clinical Site

The treatment of candidiasis depends critically on the anatomic site and patient population, with topical azoles serving as first-line for mucocutaneous disease and systemic therapy required for invasive infections.

Candidemia and Invasive Candidiasis (Non-Neonatal)

• Echinocandins are the preferred initial therapy for candidemia in adults: caspofungin (70 mg loading dose, then 50 mg daily), anidulafungin (200 mg loading dose, then 100 mg daily), or micafungin (100 mg daily) 1
• Fluconazole 400-800 mg daily (6-12 mg/kg) can be used for step-down therapy once the patient is clinically stable and the isolate is susceptible to fluconazole 1
• Amphotericin B deoxycholate 0.5-1 mg/kg daily is an alternative when echinocandins cannot be used 1
• Central venous catheter removal is strongly recommended and significantly improves outcomes 1
• Continue treatment for 2 weeks after documented clearance of Candida from the bloodstream and resolution of clinical signs 1
• Perform dilated retinal examination to rule out endophthalmitis in all patients with candidemia 1

Neonatal Candidiasis

• Amphotericin B deoxycholate 1 mg/kg daily is the preferred treatment for neonates with disseminated candidiasis 1
• Fluconazole 12 mg/kg IV or oral daily is a reasonable alternative in neonates who have not been on fluconazole prophylaxis 1
• Echinocandins should be used with caution and generally limited to salvage therapy in neonates 1
• Lumbar puncture and dilated retinal examination are mandatory in neonates with positive blood or urine cultures 1
• CT or ultrasound imaging of the genitourinary tract, liver, and spleen should be performed if blood cultures remain persistently positive 1

CNS Candidiasis (Meningitis)

• Amphotericin B deoxycholate 1 mg/kg IV daily is the recommended initial treatment for CNS candidiasis 1
• Liposomal amphotericin B 5 mg/kg daily is an alternative formulation 1
• Flucytosine 25 mg/kg four times daily may be added as salvage therapy for patients not responding to amphotericin B, though adverse effects are frequent 1
• Step-down to fluconazole 12 mg/kg daily after clinical response is appropriate for fluconazole-susceptible isolates 1
• Continue therapy until all signs, symptoms, CSF abnormalities, and radiological findings have resolved 1
• Remove infected CNS devices (ventriculostomy drains, shunts) whenever possible 1

Oropharyngeal Candidiasis (Thrush)

• Oral fluconazole 100-200 mg daily for 7-14 days is the preferred initial treatment 2, 3
• Itraconazole oral solution 200 mg daily for 7-14 days is equally effective, with clinical response rates of approximately 84% 3
• 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 2
• For fluconazole-refractory disease, itraconazole oral solution 100 mg twice daily can achieve approximately 55% complete resolution 3
• Avoid ketoconazole or itraconazole capsules due to variable absorption and inferior efficacy compared to fluconazole 2

Esophageal Candidiasis

• Systemic therapy is mandatory; topical treatment is ineffective 2
• Fluconazole 200-400 mg daily orally for 14-21 days is the preferred treatment 2
• Itraconazole oral solution 100 mg daily for a minimum of 3 weeks is an alternative, with doses up to 200 mg daily based on response 3
• Continue treatment for 2 weeks following resolution of symptoms 3
• Clinical response rates of approximately 86% are achieved with either fluconazole or itraconazole 3

Genital Candidiasis (Balanitis in Males)

• Topical azole antifungals applied 1-2 times daily for 7-14 days are first-line treatment 2, 4
• Oral fluconazole 150 mg as a single dose is equally effective and may be preferred for convenience, with 92-99% clinical cure rates 2, 4
• Topical nystatin can be used, though azoles are generally preferred 2

Vulvovaginal Candidiasis

• Either topical azole antifungals (1-7 days depending on formulation) or oral fluconazole 150 mg single dose are equally effective first-line options 4
• For recurrent vulvovaginal candidiasis (≥4 episodes per year), use fluconazole 150 mg single dose for initial treatment, followed by maintenance therapy with fluconazole 150 mg weekly for 6 months 4
• Address predisposing factors including uncontrolled diabetes, antibiotic use, immunosuppression, and poor hygiene 4

Cutaneous Candidiasis (Intertrigo, Skin Folds)

• Topical azoles (clotrimazole, miconazole, nystatin) applied 1-2 times daily for 7-14 days demonstrate 73-100% complete cure rates 2, 5
• Single-drug therapy is as effective as combinations with antibacterials or topical corticosteroids 5
• Keeping the affected area dry is as critical as the antifungal medication itself 2
• Oral fluconazole is as effective as topical clotrimazole and is the only evidence-based option for systemic treatment of cutaneous candidiasis 5
• Short-term adjuvant mild topical steroids can speed relief of discomfort when used responsibly 6

Intra-Abdominal Candidiasis

• Empiric antifungal therapy should be considered for patients with clinical evidence of intra-abdominal infection and significant risk factors including recent abdominal surgery, anastomotic leaks, or necrotizing pancreatitis 1
• Treatment must include source control with appropriate drainage and/or debridement 1
• The choice of antifungal therapy is the same as for candidemia (echinocandins preferred) 1
• Duration of therapy is determined by adequacy of source control and clinical response 1

Critical Pitfalls to Avoid

• Do not treat asymptomatic colonization: many healthy individuals carry Candida without infection; treatment should be based on clinical symptoms, not just positive cultures 2
• Do not use azole therapy in patients with recent azole exposure or prophylaxis due to increased resistance risk 4
• Asymptomatic candiduria in males does not require treatment unless the patient is neutropenic or undergoing urologic procedures 4
• Growth of Candida from respiratory secretions usually indicates colonization and rarely requires antifungal therapy 1
• For fluconazole-resistant organisms, use alternative agents such as amphotericin B deoxycholate or echinocandins 4

Special Populations

• For immunocompromised patients, consider longer treatment courses (14-21 days minimum) 2
• Suppressive therapy with fluconazole may be necessary for frequent recurrences in immunocompromised patients, though this increases resistance risk 2
• In ICU patients, daily bathing with chlorhexidine can decrease the incidence of candidemia 1
• For high-risk neutropenic patients (acute myelogenous leukemia, allogeneic bone marrow transplant), fluconazole 400 mg daily or itraconazole solution 2.5 mg/kg twice daily prophylaxis during the period of neutropenia is appropriate 1