candidiasis
CANDIDIASIS
Treatment Guideline Chart
Candida sp are the most common cause of fungal infections.
 It can cause infections that range from benign mucocutaneous illnesses to invasive process that may affect any organ.
 It is considered as normal flora in the gastrointestinal and genitourinary tracts, but when there is an imbalance in the ecological niche, they can invade and cause disease.
Most common risk factors include broad-spectrum antibiotic use, central venous catheter use, receipt of parenteral nutrition, receipt of renal placement therapy by patients in ICUs, neutropenia, implantable prosthetic device use and receipt of immunosuppressive agents.

Candidiasis Treatment

Principles of Therapy

  • When choosing an antifungal agent, consider the following factors:
    • Patient’s clinical status
    • Physician’s knowledge of the species and/or antifungal susceptibility of the infecting isolate
    • Relative drug toxicity
    • Presence of organ dysfunction that would affect drug clearance
    • Available knowledge of use of the drug in the given patient population
    • Patient’s prior exposure to antifungal agents
  • Premature discontinuation of antifungal therapy may lead to recurrent infection
  • Treatment duration depends on extent of involved organs
    • In patients with documented candidemia, duration of therapy with systemic antifungal agents should be 14 days after the first negative blood culture
    • Oral therapy may start after 10 days of intravenous (IV) therapy

Pharmacotherapy

Echinocandins
  • Eg Anidulafungin, Caspofungin, Micafungin
  • Alternative agents for patients with oropharyngeal or esophageal candidiasis unresponsive to azole therapy
  • With low minimum inhibitory concentrations for Candida sp, which provides good efficacy against esophageal and invasive candidiasis with less adverse events
  • Preferred empiric treatment in non-neutropenic intensive care unit (ICU) patients suspected with candidiasis and patients requiring intravenous therapy
  • Caspofungin requires dosage reduction for moderate to severe hepatic dysfunction
Flucytosine
  • Has broad antifungal activity against most Candida species with the exception of Candida krusei
  • Primarily used in combination with Amphotericin B (AmB) with more refractory infections such as Candida endocarditis, meningitis and endophthalmitis, and Fluconazole-resistant Candida glabrata vulvovaginal candidiasis
  • Occasionally used for symptomatic urinary tract candidiasis due to Fluconazole-resistant C glabrata
Imidazoles
  • Eg Clotrimazole, Miconazole
  • Preferred topical therapy for mild oropharyngeal candidiasis and vulvovaginal candidiasis
Polyenes
Amphotericin B (AmB)
  • Efficacious for Candida but has well-documented significant toxicity
  • Lipid formulations [eg Amphotericin B lipid complex (ABLC), Amphotericin B colloidal dispersion (ABCD), liposomal AmB] are less toxic but as effective as Amphotericin B deoxycholate (AmB-d) when used in appropriate dosages
  • Treatment alternative for patients with Fluconazole-refractory oropharyngeal or esophageal candidiasis
  • Topical formulation when combined with Flucytosine cream is used as an alternative treatment option against C glabrata infection
  • Urinary candidiasis may be the only candidal infection where lipid-associated formulas are contraindicated
    • It is theorized that the lipid-associated formulas will potentially reduce delivery of AmB and thus slow the pace of response
  • Used as alternative treatment in patients who are intolerant with other antifungal agents
Nystatin
  • Preferred oral therapy for mild oropharyngeal candidiasis
  • Also an effective treatment option for candidal skin infections and paronychia
  • Used for the prevention of recurrent oropharyngeal candidiasis
  • May cause dental caries when used over a prolonged period of time
Triazoles
Fluconazole
  • Preferred initial therapy for most adult patients with candidiasis
  • Highly effective for the treatment of superficial and invasive candidal infections
  • Oral Fluconazole is recommended in patients with moderate to severe oropharyngeal candidiasis, especially those who are unable to apply topical agents, with high aspiration risk, or in immunocompromised patients at risk for disseminated disease, and vulvovaginal candidiasis
  • Oral or IV Fluconazole is the preferred treatment for patients with esophageal candidiasis
  • Inferior to Anidulafungin but better than echinocandins against Candida parapsilosis
  • Used as an alternative treatment for patients with no recent exposure to azole and those who are not colonized by azole-resistant Candida sp
  • Recommended chronic suppressive therapy for patients with recurrent esophageal, vulvovaginal or oropharyngeal candidiasis
Isavuconazole
  • Recently approved expanded-spectrum triazole with good in vitro activity against Candida sp
  • Alternative treatment option to Fluconazole against uncomplicated esophageal candidiasis
  • It is suggested by preliminary analysis of the recently completed international double-blind trial that Isavuconazole did not meet criteria for noninferiority when compared to an echinocandin
Itraconazole
  • A useful agent for dermatologic and mucosal candidal infections but its role in invasive candidal infections has yet to be determined

Oteseconazole

  • May be considered in patients with recurrent vulvovaginal candidiasis who are not of reproductive potential
Posaconazole
  • Alternative treatment for Fluconazole-refractory oropharyngeal and esophageal candidiasis 
  • Alternative suppressive therapy for patients with recurrent esophageal candidiasis
Voriconazole
  • As active as Fluconazole against esophageal candidiasis
  • Used for mucosal and invasive candidiasis as step-down oral therapy in patients with candidal infection caused by C krusei and Fluconazole-resistant, Voriconazole-susceptible C glabrata
  • Should not be used for urinary candidiasis as it does not accumulate in active form in the urine
Other Agents
  • Topical gentian violet may be considered for mild oropharyngeal candidiasis

RECOMMENDED SITE-SPECIFIC ANTIFUNGAL THERAPY
Site of Candidal Infection Antifungal of Choice Alternative Antifungal Drugs
Cutaneous Candidiasis
Skin and paronychia Azole (topical) or
Polyene antifungal (topical)
Nystatin (topical)
Onychomycosis Itraconazole (oral) or
Terbinafine (oral)
Griseofulvin (oral)
Mucosal Candidiasis
Oropharyngeal (thrush) Fluconazole (oral)
For mild disease:
Clotrimoxazole (troches) or 
Miconazole (mucoadhesive buccal) or 
Nystatin (suspension/pastilles)
For moderate to severe disease:
Fluconazole (oral)
Itraconazole (oral solution) or
Posaconazole (oral suspension) or
Voriconazole (oral) or
AmB-d (oral suspension/IV) or 
Echinocandin (IV)
Esophageal Fluconazole (oral/IV) or
Itraconazole (oral solution)
Posaconazole (oral suspension) or
Voriconazole (oral) or
Isavuconazole or
Echinocandin (IV) or
AmB-d (IV)
Vulvovaginal candidiasis* Uncomplicated:
Fluconazole (oral) or
Topical agents
Severe/recurrent:
Fluconazole (oral)
Fluconazole (IV/oral) or
Ibrexafungerp (oral)
Chronic mucocutaneous candidiasis Fluconazole (oral) Itraconazole (oral) or
Ketoconazole (oral)**
*Please see Vaginitis: Trichomoniasis, Candidiasis, Bacterial Vaginosis disease management chart for further information.
**Serious hepatotoxicity may occur with the use of oral Ketoconazole. Please see Dosage Guidelines for more information.

Non-Pharmacological Therapy

  • Dentures should be removed, brushed thoroughly, and soaked in antiseptic solution before going to bed
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