What are the different clinical forms of candidiasis and their recommended treatments?

Types of Candidiasis and Their Recommended Treatments

Candidiasis encompasses a broad spectrum of infections ranging from superficial mucocutaneous disease to life-threatening invasive infections, each requiring distinct diagnostic and therapeutic approaches based on anatomic location, host immune status, and causative species. 1

Major Categories of Candidiasis

Invasive Candidiasis

Invasive candidiasis represents the most severe form, associated with 15-47% attributable mortality and includes multiple distinct clinical entities 1:

Candidemia (Bloodstream Infection)

• Echinocandins (caspofungin 70 mg loading then 50 mg daily, micafungin 100 mg daily, or anidulafungin 200 mg loading then 100 mg daily) are first-line therapy for most patients, particularly those who are critically ill or have had recent azole exposure 1, 2
• Fluconazole (800 mg loading, then 400 mg daily) is appropriate for less critically ill patients without recent azole exposure and with azole-susceptible species 1, 2
• Central venous catheter removal within 48-72 hours is mandatory when safely feasible, as catheter retention significantly worsens outcomes 1, 2
• Treatment duration is 2 weeks after documented blood culture clearance and symptom resolution 1, 2

Chronic Disseminated (Hepatosplenic) Candidiasis

• Occurs primarily in neutropenic patients recovering from chemotherapy 1
• Liposomal amphotericin B (3-5 mg/kg daily) is preferred initial therapy 1
• Transition to fluconazole (400-800 mg daily) for prolonged suppressive therapy after clinical stabilization 1

Central Nervous System Candidiasis

• Liposomal amphotericin B combined with flucytosine is strongly recommended due to superior CNS penetration 1
• Echinocandins should be avoided due to poor CNS penetration 1
• Fluconazole (400-800 mg daily) is appropriate for consolidation therapy if the isolate is susceptible 1

Ocular Candidiasis (Endophthalmitis)

• Fluconazole or voriconazole is preferred for azole-susceptible species due to excellent ocular penetration 1
• Liposomal amphotericin B is reserved for azole-resistant infections 1
• Echinocandins have poor posterior chamber penetration and should be avoided for endophthalmitis 1
• Intravitreal antifungal therapy or vitrectomy may be required for severe cases 1

Cardiovascular Candidiasis (Endocarditis, Device Infections)

• Requires surgical intervention for valve replacement or device removal in most cases 1
• Liposomal amphotericin B (3-5 mg/kg daily) with or without flucytosine is preferred initial therapy 1
• Prolonged suppressive therapy (often lifelong) is necessary if surgical source control is incomplete 1

Osteoarticular Candidiasis

• Fluconazole (400 mg daily) for 6-12 months is preferred for azole-susceptible species 1
• Echinocandins or liposomal amphotericin B for initial therapy in severe cases or azole-resistant species 1
• Surgical debridement is often required for osteomyelitis or septic arthritis 1

Intra-abdominal Candidiasis

• Source control through surgical or percutaneous drainage is essential 1
• Echinocandins are first-line for empiric therapy 1
• Fluconazole is appropriate for azole-susceptible species after source control 1

Urinary Tract Candidiasis

• Asymptomatic candiduria rarely requires treatment except before urologic procedures 1
• Fluconazole (200-400 mg daily for 2 weeks) is preferred for symptomatic cystitis 1
• Liposomal amphotericin B or an echinocandin for pyelonephritis or azole-resistant species 1

Mucocutaneous Candidiasis

Oropharyngeal Candidiasis (Oral Thrush)

• Fluconazole 200 mg loading dose followed by 100 mg daily for 14 days is first-line therapy 3
• Clinical improvement typically occurs within 48-72 hours 3
• Topical clotrimazole troches (10 mg dissolved orally 5 times daily) are reasonable alternatives for immunocompetent patients with initial episodes 3
• Nystatin suspension or miconazole mucoadhesive tablets are additional topical options 3
• For azole-refractory disease, itraconazole oral solution (200 mg daily) or posaconazole suspension (400 mg twice daily) are effective 3
• HIV/AIDS patients should receive antiretroviral therapy optimization to reduce recurrence 3

Esophageal Candidiasis

• Fluconazole (200-400 mg daily for 14-21 days) is first-line therapy 1
• Itraconazole solution (200 mg daily) or voriconazole for fluconazole-refractory cases 1
• Echinocandins (IV) or liposomal amphotericin B for severe or refractory disease 1

Vulvovaginal Candidiasis

• Uncomplicated cases: Single-dose oral fluconazole 150 mg or topical azoles (clotrimazole, miconazole) for 1-7 days 1
• Complicated/recurrent cases: Fluconazole 150 mg on days 1,4, and 7, followed by maintenance therapy (fluconazole 150 mg weekly for 6 months) 1

Cutaneous Candidiasis

• Topical clotrimazole, nystatin, or miconazole demonstrate equal efficacy with 73-100% cure rates 4
• Single-drug topical therapy is as effective as combination products containing antifungals, antibacterials, and corticosteroids 4
• Oral fluconazole is as effective as topical therapy and is the only evidence-based systemic option 4

Neonatal Candidiasis

• Amphotericin B deoxycholate (1 mg/kg daily) is preferred for invasive disease in neonates 1
• Fluconazole (12 mg/kg loading, then 6 mg/kg daily) is an alternative for less severe infections 1
• Echinocandins have limited data in neonates but may be considered in specific circumstances 1

Species-Specific Treatment Considerations

Candida glabrata

• Echinocandins are strongly preferred due to frequent azole resistance 1, 2, 5
• Fluconazole should be avoided as initial therapy 1, 2, 5
• Transition to fluconazole only after confirmed susceptibility, clinical stability, and negative follow-up cultures 1, 2
• In MPO-deficient patients, echinocandins are the definitive first-line agents due to impaired cellular immunity 5

Candida parapsilosis

• Fluconazole is preferred due to higher echinocandin MICs for this species 1, 2
• Continuation of echinocandin is reasonable if already receiving, clinically improved, and follow-up cultures are negative 1, 2

Candida krusei

• Intrinsically resistant to fluconazole 1
• Echinocandins, liposomal amphotericin B, or voriconazole are appropriate options 1, 2

Candida auris

• Emerging multidrug-resistant pathogen requiring infection control measures 1
• Echinocandins are typically first-line, but susceptibility testing is essential 1
• Combination therapy may be necessary for resistant isolates 1

Critical Management Principles

Antifungal susceptibility testing is mandatory for all bloodstream and clinically relevant isolates to guide definitive therapy 2, 5. Species identification alone is highly predictive of susceptibility patterns but cannot replace formal testing 1.

Common pitfalls to avoid:

• Never use fluconazole empirically in critically ill patients or those with recent azole exposure—echinocandins have superior outcomes 2
• Never leave central venous catheters in place when candidemia is documented—catheter retention significantly increases mortality 2
• Never stop therapy prematurely—ensure full 2-week course after blood culture clearance 2
• Never assume all Candida species have identical susceptibility—species identification is essential 2
• Never dismiss Candida colonization as benign in immunocompromised patients, particularly those with MPO deficiency 5