Candidiasis, systemic and other

B37

DESCRIPTION

Superficial and/or disseminated (systemic) fungal infection caused by C. albicans , C. Tropicalis and other candida species.

Risk factors include:

  • Prolonged, broad-spectrum antibiotic therapy.
  • Compromised immune system, including patients infected with HIV or on cancer chemotherapy, and the premature baby.
  • Steroid therapy.
  • Diabetes mellitus.
  • IV hyperalimentation – contaminated solution or as an associated risk factor.
  • Instrumentation, and central or peripheral vascular catheters.

DIAGNOSTIC CRITERIA

Clinical

  • Oral candidiasis (thrush):
    • White plaque adheres to inner cheeks, lips, palate and tongue.
    • Stomatitis with red mucosa and ulcers may also be present.
    • In immunocompromised patients, the lesions may extend into the oesophagus.
  • Oesophageal candidiasis:
    • Presents as difficulty swallowing, drooling or retrosternal pain (irritability in small children).
  • Skin lesions in the newborn:
    • A red, maculopapular or pustular rash is seen in infants born to women with candida amnionitis.
  • Cutaneous lesions:
    • May be represented by scattered, red papules or nodules.
    • Superficial infections of any moist area, such as axillae or neck folds, are common and may present as an erythematous, intertriginous rash with satellite lesions.
  • Vulvovaginitis:
    • A thick cheesy vaginal discharge with intense pruritus, white plaques on the glans of the penis.
    • Common in diabetics and patients on broad-spectrum antibiotics.
    • In recurrent vulvovaginitis, exclude diabetes, foreign body or sexual abuse.
  • Systemic or disseminated candidiasis:
    • Mimics bacterial sepsis but fails to respond to antibiotics.
    • Thrombocytopaenia is common.
    • Ophthalmitis with “cotton wool” retinal exudates may also occur.
    • Is usually nosocomial.

Investigations:

  • For oesophageal candidiasis:
    • It is reasonable to initiate treatment on clinical suspicion
    • Oesophagoscopy or barium swallow.
  • Systemic candidiasis:
    • Urine and blood fungal cultures are essential.
    • Biopsy specimens, fluid or scrapings of lesions: budding yeasts and pseudohyphae are seen on microscopy.

GENERAL AND SUPPORTIVE MEASURES

  • Encourage cup feeding of formula-fed infants, as bottles are difficult to clean and predispose to candida infection.
  • Eradicate or minimise risk factors.
  • Avoid use of pacifiers (dummies), teats and bottles but if used, these should be sterilised.
  • Remove all invasive devices, drain abscesses and debride infected tissue.

MEDICINE TREATMENT

Oral candidiasis

  • Nystatin suspension 100 000 IU/mL, oral, 1 mL 4 hourly.
    • Keep in contact with affected areas for as long as possible.

Suspect immunodeficiency if poor response to treatment.
If no response:

  • Imidazole oral gel, e.g.:
  • Miconazole gel 2%, oral, apply 8 hourly.

Oesophageal candidiasis

  • Fluconazole, IV/oral, 6 mg/kg immediately as a single dose.
    • Follow with 3 mg/kg/day for 3 weeks.

LoEIII [1]

Vulvovaginitis

  • Fluconazole, oral, 12 mg/kg as a single dose.
    • Maximum dose: 150 mg.

OR

  • Imidazole topical/vaginal, e.g.
  • Clotrimazole OR miconazole, applied locally at night for 7–14 days.
    • Do not use applicator in girls who are not sexually active.

Systemic candidiasis

  • Amphotericin B deoxycholate, IV infusion in 5% dextrose water only , 1 mg/kg/dose once daily over 4 hours for at least 2 weeks after first negative culture, or if no repeat culture available at least 3 weeks after clinical improvement.
    • Maximum cumulative dose: 30–35 mg/kg over 4–8 weeks.
    • Adjust dosing interval in patients with renal impairment.
    • Protect the bag from light during infusion.
    • Check serum potassium and magnesium at least 3 times a week.
    • Do not use bacterial filter with amphotericin B.

Prehydration before administering amphotericin to prevent renal impairment:

  • Sodium chloride 0.9%, IV, 15 mL/kg plus potassium chloride, 20 mmol/L infused over 2–4 hours.

REFERRAL

  • Candidiasis not responding to adequate therapy.
  • Patients with renal and hepatic failure.
  • Confirmed azole resistance.