Emergency Department Care
Mucocutaneous candidiasis is often encountered and treatment initiated in the emergency department. Systemic infections in patients with risk factors for Candida infection should be admitted to the hospital and cultures taken prior to initiating antimicrobial therapy. [28, 25]
Other treatment of candidiasis
Generally, the echinocandin class of antifungals should be used as the first-line treatment of candidemia (ie, critically ill patients or patients with prior azole treatment). Unfortunately, there are already reports of echinocandin resistance after long-term therapy for candidemia. [29]
Polyenes should not be used to treat patients who have renal failure, and echinocandins and azoles should not be used in patients with severe liver disease because of their respective side effect profiles and pharmacokinetic properties. [30]
Mucocutaneous infection of the oropharynx typically responds to topical therapy. Nystatin is the least expensive option for oral thrush, but patients frequently complain of its bitter taste. Clotrimazole troches are as effective and less bitter. Proper denture cleansing and care are important measures against oral candidiasis. Systemic therapy is first line for esophageal candidiasis, with fluconazole as the preferred first-line agent.
Intertrigo and diaper rash respond to decreased moisture around the skin. Nystatin powder or cream is used with the addition of a topical steroid for diaper rash.
Uncomplicated vulvovaginal candidiasis treatment includes many options of topical or oral therapy. Recurrent candidal vaginitis requires a prolonged course of oral medication; probiotic Lactobacillus may help in facilitating treatment of this disease. [31]
A 2020 Cochrane Library systematic review and meta-analysis showed, with a moderate certainty, that oral treatment probably improves both short term and long-term cure of vulvovaginal candidiasis when compared to intravaginal therapy. The benefit is significant, but potentially marginal. The data suggested that if short term intravaginal therapy cure rates are 80%, then oral therapy would have a cure rate of 80-85%. If long term intravaginal therapy cure rates are 66%, then oral therapy would have a cure rate of 67-76%. Thus, given the marginal benefit, the authors of this review suggest that medication availability, side effects, cost, and use preference all be considered when deciding on method of therapy. [32]
Invasive candidiasis typically requires parenterally administered antifungal therapy.
Candida endocarditis frequently requires both medical and surgical therapy. Valve replacement and vegetation removal are often necessary. Antifungal therapy is typically continued for 6 to 10 weeks parenterally.
CNS candidal infection can often successfully be treated without intrathecal instillation.
Peritoneal candidal infection secondary to peritoneal dialysis may respond to peritoneal infusion of antifungal agents in dialysate fluid.
Candida keratitis may require corneal grafting if not responsive to treatment.
Full-term infants with Candida amnionitis typically respond to topical therapy. Premature infants frequently require systemic antifungal agents and have a poorer prognosis.
Endophthalmitis may require vitrectomy and direct intravitreal antifungal instillation.
Consultations
Infectious disease specialists are typically involved in cases of invasive candidiasis.
Gastroenterologists typically perform diagnostic endoscopy.
Surgical drainage may be required with organ involvement and abscess formation.
Orthopedic surgeons are involved in the management of osteomyelitis and intra-articular infections.
Cardiothoracic surgeons are frequently necessary in the treatment of endocarditis.
Ophthalmologic consultation should be obtained for all patients with candidemia to exclude evidence of ocular involvement.
Dermatologist consulation can be considered in treatment resistant cutaneous/mucocutaneous candidiasis.
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Candidiasis. Image courtesy of Hon Pak, MD.
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Candidiasis. A moist, erosive, pruritic patch of the perianal skin and perineum (with satellite pustule formation) is demonstrated in this woman with extensive candidosis. Image courtesy of Matthew C Lambiase, DO.
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Candidiasis. Discrete superficial pustules developed within hours of birth on the hand of an otherwise healthy newborn. A potassium hydroxide preparation revealed spores and pseudomycelium, and culture demonstrated the presence of Candida albicans. Image courtesy of Matthew C Lambiase, DO.
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Candidiasis. Dry, red, superficially scaly, pruritic macules and patches on the penis represent candidal balanitis. Image courtesy of Matthew C Lambiase, DO.
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Candidiasis. White plaques are present on the buccal mucosa and the undersurface of the tongue and represent thrush. When wiped off, the plaques leave red erosive areas. Image courtesy of Matthew C Lambiase, DO.
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Candidiasis. Erythema, maceration, and satellite pustules in the axilla, accompanied by soreness and pruritus, result in a form of intertrigo. Image courtesy of Matthew C Lambiase, DO.
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Candidiasis. A nailfold with candidal infection becomes erythematous, swollen, and tender with an occasional discharge. Image courtesy of Matthew C Lambiase, DO.
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Candidiasis. Soreness and cracks at the lateral angles of the mouth (angular cheilitis) is a frequent expression of candidosis in elderly individuals. Image courtesy of Matthew C Lambiase, DO.
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Candidiasis. Fine superficial pustules on an erythematous patchy base are suggestive of candidosis. Image courtesy of Matthew C Lambiase, DO.
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Candidiasis. Candida infection should be in the differential diagnosis when one or more nails become discolored, has subungual discoloration, nailplate separation from the nailbed, and lack evidence of a dermatophyte. Image courtesy of Matthew C Lambiase, DO.
