AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Candidal infections are extremely common. Candida albicans is the most common cause of human candidal infections, but other pathogenic species include C glabrata, C parapsilosis, C tropicalis, C krusei, C lusitaniae, and C stellatoidea.

Pathophysiology

Infections caused by Candida may affect numerous organ systems, such as the eyes, lungs, kidneys, heart, and central nervous system (CNS).

Skin

The most common manifestation of candidal infection is diaper dermatitis in infants. Candida organisms also can cause intertrigo in older individuals. Intertrigo has a predilection for dark moist areas, such as the groin or fat folds. Predisposing conditions include diabetes mellitus, obesity, and hyperhidrosis.

Nails

A chronic paronychia may be caused by one of several Candida species. Candida organisms also can cause onychomycosis, including total nail dystrophy due to chronic mucocutaneous candidiasis, a rare T-cell disorder.

Mucous membranes

Thrush, or oral candidiasis, also is common in infants. Oral candidiasis also may be an adverse effect from using inhaled corticosteroids for asthma due to oral deposition. Patients who are immunocompromised may suffer from candidal esophagitis as well as thrush.

Genitals

Vaginal yeast infections affect nearly 75% of women. Male partners may develop balanitis or balanoposthitis. Individuals with chronic indwelling catheters also are predisposed to recurrent candidal infections.

Systemic

Candida organisms can cause severe systemic infections in immunocompromised patients, compared to benign cutaneous or localized infections in the immunocompetent patient. Reports of systemic candidiasis are common in children with AIDS and other immune deficiencies, as well as in very low birth weight premature infants. Manifestations include fungemia, endophthalmitis, meningitis, renal or bladder bezoars, and arthritis.

Virulence factors

A number of factors can contribute to the likelihood of candidal infections. An intact skin barrier is protective. Candidal infections are promoted in the face of lymphocyte dysfunction, as is observed in persons with AIDS and those with chronic mucocutaneous candidiasis (CMCC). Adherence of Candida organisms to oral and vaginal epithelium is believed to be promoted by biologic factors (eg, fibronectin in thromboses) and by iatrogenic factors (eg, presence of plastic catheters, disruption of normal bacterial flora). In neonates, risk factors include indwelling catheters, prolonged antibiotic use, necrotizing enterocolitis, previous bloodstream infections, total parenteral nutrition, and low birth weight.

Chronic mucocutaneous candidiasis

CMCC is a heterogeneous group of disorders characterized by chronic candidal infections of the nails, skin, and mucous membranes. Most CMCC disorders are autosomal recessive and related to a mutation in the AIRE gene. Lymphocyte numbers are normal; however, response to in vitro exposure to candidal antigen is absent.

Frequency

United States

Thrush occurs in approximately 2-5% of healthy newborns and a slightly higher percentage of infants in the first year of life. Vaginal candidal infections occur in approximately 75% of women, and 40-50% of women experience recurrence. Approximately 2-5% of premature infants weighing less than 1500 g develop disseminated disease.

Mortality/Morbidity

Candidal infections rarely cause significant morbidity in the healthy host. However, systemic disease may be found in as many as 15% of patients who are neutropenic. Mortality in low birth weight premature infants with systemic candidiasis may reach 50%. Candida is the second leading cause of sepsis in critical care patients.

Race

No racial predilection exists.

Sex

Vaginal candidosis is a frequent problem among women and adolescent girls. No gender predilection exists for other forms of candidiasis.

Age

In the healthy host, candidal infections are most common in the first year of life as thrush or diaper dermatitis. Vulvovaginitis is more common in adolescent and adult females.

CLINICAL

Section 3 of 11  

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History

• Thrush: Infants with thrush may experience pain, poor feeding, or fussiness.

• Cutaneous candidiasis
• • Patients with cutaneous candidiasis experience itching, burning, and soreness.

  • Most commonly affected areas are the diaper area in infants and toddlers and abdominal fat folds and groin in older individuals.

• Paronychia and onychomycosis
• • Candidal paronychia and nail disease has a predilection for the fingernails.

  • Paronychia usually is painful.

• Vulvovaginitis
• • Most women with vulvovaginitis complain of a creamy vaginal discharge with soreness and burning.

  • Dyspareunia often is present.

• Otitis externa
• • Otitis externa is found most commonly in tropical and subtropical climates.

  • Malnutrition and immunosuppression are risk factors.

  • Candidiasis is clinically difficult to distinguish from other causes of otitis externa.

• Gastrointestinal candidiasis
• • GI candidiasis primarily is observed in individuals who are immunocompromised, especially in persons with HIV infection and/or primary immunodeficiency.

  • This may be a cause of chronic diarrhea.

  • Common in infants, glossitis may occur in older children following use of broad-spectrum antibiotics or may signal immunodeficiency.

  • Esophagitis should be suspected in individuals who are immunocompromised when oral candidiasis is present. Symptoms include dysphagia and odynophagia. Risk of esophagitis is elevated in children taking H2 blockers.

• Pneumonia: This is extremely rare and usually results from disseminated disease.
• Cystitis: Risk factors for cystitis include indwelling urinary catheters, immunosuppression, diabetes mellitus, and use of broad-spectrum antibiotics.

• Endophthalmitis
• • Endophthalmitis is the most common intraocular infection in newborns.

  • Risk factors include low birth weight and prolonged hospitalization.

• CNS infections
• • CNS infections usually present as subacute meningitis.

  • Risk factors include indwelling catheters (especially shunts), prematurity, malnutrition, immunodeficiency, and organ transplantation.

• Endocarditis: Risk factors for endocarditis include immunosuppression, HIV infection, intravenous catheters, corticosteroid use, prolonged hospitalization, and use of broad-spectrum antibiotics.
• Hepatic (hepatosplenic) candidiasis
• • Risk factors include neutropenia.

  • Hepatic candidiasis may present with fever of unknown origin. It usually is a manifestation of disseminated candidiasis.

Physical

• Thrush
• • White plaques are observed in the mouth and may affect the lips, tongue, gums, and palate.
  • Scraping of the lesions may reveal erythema and bleeding at the base (see Image 1). The plaques do not scrape off easily.


• Cutaneous candidiasis
• • Lesions consist of beefy-red plaques, often with scalloped borders.
  • Satellite papules and pustules may be observed surrounding the plaques.
  • Maceration often exists, especially in intertriginous areas (see Image 2).
  • Candidal diaper dermatitis generally is confluent in intertriginous areas, while generic diaper dermatitis may demonstrate sparing in the folds.


• Paronychia and onychomycosis
• • Paronychia typically involves the cuticular fold of fingernails, causing redness, swelling, and pain.
  • Pus may be present.
  • Nail involvement usually stems from long-standing paronychia and causes a yellow discoloration of the nail, often with separation of the nail from the nail bed.


• Genital candidiasis
• • With vulvovaginitis, a creamy white discharge usually is present. White plaques may be observed on an erythematous base of the vaginal mucosa or vulvar skin. Papules and pustules may be present.
  • With balanitis, lesions usually are observed on the glans penis and consist of erythematous plaques, pustules, or erosions.


• Gastrointestinal disease
• • Glossitis is characterized by creamy or curdlike white plaques, which may be painful and bleed beneath when scraped.
  • With esophagitis, oral candidiasis may or may not be present. Weight loss is common.


• Otitis externa
• • Tenderness of the pinna, aural discharge, and erythema characterize otitis externa.
  • Lymphadenopathy of postauricular or preauricular nodes may be present.
  • A grayish membrane may be present in the canal.


• Hepatic candidiasis: This infection usually presents as abscesses in the liver and/or spleen.
• Endocarditis
• • Endocarditis is characterized by fever and a new or changing heart murmur.
  • Symptoms relating to embolization to other organs (eg, CNS, kidneys, lungs, retina and choroid, skin) may be present.


• Endophthalmitis
• • White well-circumscribed lesions of the retina and choroid in the posterior pole characterize endophthalmitis.
  • Isolation of candida from blood, urine, or other sources supports the diagnosis of endophthalmitis.


• CNS infections
• • Signs consistent with meningitis are often present with CNS infections.
  • Evidence of candidal infection of other organ systems may be present.

Causes

Candidal infections have differing presentations in patients who are immunocompetent versus persons who are immunocompromised.

• Patient who is immunocompetent
• • While candidal diaper rash is common in healthy infants, predisposing factors causing candidal infections in older individuals often exist.
  • The most common factor is the disruption of normal flora following a course of antibiotic therapy, which is observed most commonly as cutaneous candidiasis or vulvovaginitis.
  • Other risk factors for candidal infection relate to impaired immune function, including individuals with diabetes mellitus, premature infants, hosts who are immunocompromised, and persons using systemic or topical corticosteroids.
  • Other risk factors include obesity, heat, and excessive sweating.

• Patient who is immunocompromised
• • Individuals who are immunocompromised are more susceptible to oral and cutaneous candidiasis and often have a more severe course.
  • Oral candidiasis may appear as acute or chronic atrophic candidiasis, which causes painful red erosions of the tongue and mucous membranes.
  • Candida species are frequent causes of central venous catheter infections.
  • Immunosuppression also may cause systemic candidiasis, which may present as fungemia or funguria. Candida species may cause fungal bezoars in the kidney or bladder, or candidiasis may cause abscesses in the liver or spleen. Candidal meningitis, arthritis, and endophthalmitis all have been reported.

• Neonates
• • Neonates with very low birth weight are at a higher risk of developing candidemia.
  • Risk factors include low birth weight, broad spectrum antibiotic use, total parental nutrition, previous bloodstream infections, or necrotizing enterocolitis.

• Chronic mucocutaneous candidiasis: CMCC is a cluster of disorders of cell-mediated immunity that presents as chronic severe candidal infections of the skin and mucous membranes.

DIFFERENTIALS

Section 4 of 11  

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Other Problems to be Considered

Langerhans cell histiocytosis
Paronychia
Seborrheic dermatitis

WORKUP

Section 5 of 11  

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Lab Studies

• Potassium hydroxide (KOH) slide preparation: Scrapings of oral or cutaneous lesions may demonstrate budding yeasts with pseudohyphae.
• Cultures
• • Blood culture is highly insensitive; fewer than 15% of patients with disseminated disease have positive blood cultures.
  • Urine culture often is positive in individuals who are immunocompromised and have renal or bladder disease.
  • Culture intravascular devices, especially indwelling catheters and especially in neonates suspected of having sepsis.

• Alpha-glucan assay - Component of fungal cell wall
• D-arabinatol assay - Measures fungal metabolite

Imaging Studies

• Ultrasound and computed tomography scanning may be helpful in making the diagnosis of disseminated candidal infection in the individual who is immunocompromised, especially for renal, bladder, hepatic, and splenic lesions.
• Endoscopy may be indicated for diagnosis of candidal esophagitis, especially when empiric treatment has failed.

Procedures

• Lumbar puncture is indicated for patients suspected of having candidal meningitis. Findings may include the following:
• • Elevated opening pressure
  • Increased WBC count, often with predominance of lymphocytes
  • Hyphae, which may be observed on Gram stain

TREATMENT

Section 6 of 11  

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Medical Care

Treatment of candidal infections primarily is accomplished with appropriate antifungal drugs.

Surgical Care

Remove the offending catheter in central venous catheter infection, because attempts to treat the infection without its removal are largely unsuccessful and are accompanied by high morbidity and mortality.

Consultations

• Consult the infectious disease service for patients suspected of having systemic candidal infections, especially in the host who is immunocompromised.
• Consult ophthalmology for suspected endophthalmitis in neonates.

Diet

No specific diet is required.

Activity

No restrictions are required.

MEDICATION

Section 7 of 11  

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Candidal infections are sensitive to a broad range of antifungal agents. Nystatin and one of the imidazoles are the most commonly used agents for oral or cutaneous candidiasis.

Noting the resistance pattern in your area is important; reports of fluconazole-resistant Candida exist.

Future medications include a new group of antifungal agents, the echinocandins (eg, caspofungin, micafungin, anidulafungin), that are now being studied in children and adults. The mechanism of action of this group is to interfere with the cell wall integrity inhibiting 1,3 alpha-D-glucan synthase. These new agents are currently not FDA-approved for use in the pediatric population, although considerable experience with caspofungin suggests its safety and efficacy.

Drug Category: Topical antifungals (oral preparations)

These agents are used for the treatment of oral candidiasis (thrush).

Drug Name	Gentian violet
Description	Effective as second-line agent for oral candidiasis resistant to nystatin.
Adult Dose	Apply to affected areas tid
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Stains skin and clothing

Drug Category: Topical antifungals (dermatologic)

These agents are used to treat cutaneous candidiasis.

Drug Name	Clotrimazole 1% cream (Lotrimin, Mycelex)
Description	Second-line agent in treatment of cutaneous candidiasis.
Adult Dose	Apply to affected area bid until 48 h after resolution of lesions
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Not for treatment of systemic fungal infections; avoid contact with eyes; if irritation or sensitivity develops, discontinue use and institute appropriate therapy

Drug Name	Miconazole 2% cream (Absorbine, Micatin)
Description	Alternate topical antifungal. Lotion is preferred in intertriginous areas. If cream is used, apply sparingly to avoid maceration effects.
Adult Dose	Apply to affected areas bid until 48 h after resolution of lesions
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes

Drug Category: Systemic antifungals (oral)

These agents are used for treatment of cutaneous infections refractory to treatment by topical agents or as adjunctive therapy for systemic candidal infection.

Drug Name	Itraconazole (Sporanox)
Description	Effective oral systemic antifungal. Fungistatic activity. Synthetic triazole antifungal agent that slows fungal cell growth by inhibiting CYP450-dependent synthesis of ergosterol, a vital component of fungal cell membranes.
Adult Dose	Oral candidiasis: 100 mg PO qd for 15 d Vulvovaginitis: 200 mg PO bid for 1-3 d
Pediatric Dose	3-5 mg/kg/d PO divided qd/bid
Contraindications	Documented hypersensitivity; coadministration with cisapride may cause adverse cardiovascular effects (possibly death); coadministration with alprazolam and triazolam
Interactions	Potent inhibitor of CYP3A4; antacids may reduce absorption of itraconazole; edema may occur with coadministration of calcium channel blockers (eg, amlodipine, nifedipine); hypoglycemia may occur with sulfonylureas; may increase tacrolimus and cyclosporine plasma concentrations when high doses are used; rhabdomyolysis may occur with coadministration of HMG-CoA reductase inhibitors (lovastatin or simvastatin); coadministration with cisapride can cause cardiac rhythm abnormalities and death; may increase digoxin levels; coadministration may increase plasma levels of midazolam, alprazolam, or triazolam; phenytoin and rifampin may reduce itraconazole levels (phenytoin metabolism may be altered)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	May cause nausea, vomiting, diarrhea, hypokalemia, and elevated transaminases; hepatic metabolism; does not penetrate CSF well

Drug Name	Ketoconazole (Nizoral)
Description	Well absorbed orally. Administer with food to reduce nausea and vomiting. Imidazole broad-spectrum antifungal agent. Inhibits synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.
Adult Dose	Superficial candidal infection (oral, vaginal, esophageal): 200 mg PO qd for 1-2 wk
Pediatric Dose	>2 years: 3.3-6.6 mg/kg/d PO qd
Contraindications	Documented hypersensitivity; fungal meningitis
Interactions	Potent inhibitor of CYP3A4; isoniazid may decrease bioavailability; coadministration decreases effects of either rifampin or ketoconazole; may increase effect of anticoagulants; may increase toxicity of corticosteroids and cyclosporine (cyclosporine dosage can be adjusted); may decrease theophylline levels
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Hepatotoxicity may occur; may reversibly decrease corticosteroid serum levels (adverse effects avoided with dose of 200-400 mg/d); administer antacid, anticholinergics, or H2 blockers at least 2 h after taking

Drug Name	Flucytosine (Ancobon)
Description	Also known as 5-FC. Converted to fluorouracil after penetrating fungal cells. Inhibits RNA and protein synthesis. Active against Candida and Cryptococcus species and generally used in combination with amphotericin B.
Adult Dose	50-150 mg/kg/d PO divided q6h
Pediatric Dose	Neonates: 80-160 mg/kg/d PO divided q6h Children: 50-150 mg/kg/d PO divided q6h
Contraindications	Documented hypersensitivity
Interactions	Amphotericin B may increase toxicity of flucytosine; cytosine may inactivate flucytosine
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Monitor CBC count, creatinine, alkaline phosphatase, AST, and ALT; may cause anemia, leukopenia, or thrombocytopenia; therapeutic levels 25-100 mg/L; adjust dose in renal failure

Drug Name	Posaconazole (Noxafil)
Description	Triazole antifungal agent. Blocks ergosterol synthesis by inhibiting the enzyme lanosterol 14-alpha-demethylase and sterol precursor accumulation. This action results in cell membrane disruption. Available as oral susp (200 mg/5 mL). Indicated for prophylaxis of invasive Aspergillus and Candida infections in patients at high risk due to severe immunosuppression.
Adult Dose	200 mg (5 mL) PO tid with food or liquid nutritional supplement to enhance absorption
Pediatric Dose	<13 years: Not established >13 years: Administer as in adults
Contraindications	Documented hypersensitivity; coadministration with ergot alkaloids; coadministration with CYP3A4 substrates likely to result in serious toxicities (eg, terfenadine, astemizole, cisapride, pimozide, halofantrine, quinidine)
Interactions	Metabolized via UDP glucuronidation; P-gp efflux substrate; CYP3A4 inhibitor UDP-G inducers (eg, rifabutin, phenytoin) and drugs that increase gastric pH (eg, cimetidine) decrease serum levels (avoid concomitant use unless benefit outweighs risk) Inhibits CYP3A4 and may elevate serum levels of cyclosporine, tacrolimus, sirolimus, rifabutin, midazolam, phenytoin, calcium channel blockers (eg, nifedipine, bepridil), HMG-CoA reductase inhibitors (eg, lovastatin, pravastatin), ergot alkaloids, terfenadine, astemizole, cisapride, pimozide, halofantrine, quinidine, or vinca alkaloids (eg, vincristine, vinblastine)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Common adverse effects include nausea, vomiting, diarrhea, rash, hypokalemia, thrombocytopenia, and elevated liver enzyme levels; closely monitor patients with severe diarrhea or vomiting for breakthrough fungal infections; rare adverse events include arrhythmias caused by QTc prolongation, bilirubinemia, or liver function impairment; caution with preexisting cardiac risk factors (eg, history of arrhythmia, hypokalemia, hypomagnesemia); food improves absorption and provides optimal serum concentration; shake well before use; administer with measuring spoon provided in package; avoid if breastfeeding

Drug Category: Systemic antifungals (intravenous)

The mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal cell.

Drug Name	Amphotericin B, liposome (AmBisome)
Description	Amphotericin B in a 10% lipid emulsion appears to have less nephrotoxicity than standard preparation of amphotericin. Lipid emulsion does not appear to decrease antifungal properties of amphotericin B.
Adult Dose	5 mg/kg IV as single infusion administered no faster than 2.5 mg/kg/h
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Antineoplastic agents or other nephrotoxic drugs (eg, aminoglycosides, cyclosporine) may enhance potential of amphotericin B for renal toxicity, bronchospasm, and hypotension; corticosteroids, digitalis, and thiazides may potentiate hypokalemia
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Although less nephrotoxic than standard amphotericin preparations, use caution in patients with decreased renal function; monitor BUN and creatinine levels; LFT, electrolytes, and CBC count; may require premedication with antihistamines, corticosteroids or analgesics to decrease risk of headache, chills, fever, or rigors

Drug Name	Amphotericin B desoxycholate (Amphocin, Fungizone)
Description	DOC for treatment of systemic fungal infections. Polyene antibiotic produced by strain of Streptomyces nodosus; can be fungistatic or fungicidal. Binds to sterols (eg, ergosterol) in fungal cell membrane, causing intracellular components to leak with subsequent fungal cell death. Premedication with acetaminophen may help reduce rigors, chills, and fever associated with infusion. Hydrocortisone directly added to infusate also may reduce febrile reactions.
Adult Dose	Test dose: 1 mg IV administered over 30 min Initial dose: 0.25-0.5 mg/kg/d IV qd/qod administered over 2-6 h Increment: Increase as tolerated by 0.25-0.5 mg/kg/d Maintenance: 0.25-1 mg/kg/d or 1-1.5 mg/kg qod
Pediatric Dose	Test dose: 0.1 mg/kg IV, not to exceed 1 mg; administer over 20-60 min Initial dose: 0.25-0.5 mg/kg/d IV qd/qod administered over 2-6 h Increment: Increase as tolerated by 0.25-0.5 mg/kg/d Maintenance: 0.25-1 mg/kg/d or 1-1.5 mg/kg qod
Contraindications	Documented hypersensitivity
Interactions	Antineoplastic agents or other nephrotoxic drugs (eg, aminoglycosides, cyclosporine) may enhance potential of amphotericin B for renal toxicity, bronchospasm, and hypotension; corticosteroids, digitalis, and thiazides may potentiate hypokalemia
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Monitor renal function, serum electrolytes (eg, magnesium, potassium), liver function, CBC, and hemoglobin concentrations; resume therapy at lowest level (eg, 0.25 mg/kg) when therapy is interrupted for > 7 d; hypoxemia, acute dyspnea, and interstitial infiltrates may occur in patients who are neutropenic and who are receiving leukocyte transfusions (separate time of amphotericin infusion from time of leukocyte transfusion); fever and chills are common after first few administrations, premedication with antihistamines, corticosteroids, and analgesics may diminish reaction; rare acute reactions may include hypotension, bronchospasm, arrhythmias, and shock

Drug Name	Caspofungin (Cancidas)
Description	First of a new class of antifungal drugs (glucan synthesis inhibitors). Inhibits synthesis of beta-(1,3)-D-glucan, an essential component of fungal cell wall.
Adult Dose	50 mg IV qd
Pediatric Dose	1 mg/kg/d qd for the first 2 d then 2 mg/kg/d qd thereafter has been used for neonates in early studies
Contraindications	Documented hypersensitivity
Interactions	Coadministration with cyclosporine may increase risk of hepatotoxicity; carbamazepine, nelfinavir, efavirenz, or dexamethasone may decrease levels of caspofungin; caspofungin may decrease levels of tacrolimus; rifampin decreases caspofungin levels by 30% (ie, adjust dose to 70 mg/d)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in moderate hepatic dysfunction (ie, decrease dose to 35 mg/d); may exacerbate pre-existing renal dysfunction or myelosuppression

FOLLOW-UP

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Transfer

• Transfer is appropriate if the required level of care is not available locally.

Deterrence/Prevention

• The risk of candidal diaper rash may be reduced by preventing irritant diaper dermatitis by using absorbent diapers and preventing excessive exposure to urine or feces.
• Encourage parents to appropriately clean their infant's bottles while they are treated for thrush.
• Encourage asthma patients to rinse their mouth after using their corticosteroid inhaler.
• Keep hands dry; when wet work is unavoidable, use rubber gloves with cotton liners. Response is generally quite good to topical azoles.
• Cutaneous candidiasis may be prevented by keeping areas cool and dry and by using breathable fabrics (eg, cotton).
• Fluconazole is used extensively in patients with neutropenia, persons undergoing organ transplantation, and in extremely low birth weight infants. While found to be generally safe in these populations and able to reduce candidal colonization, effect on survival has been minimal. New studies show prophylactic doses of Fluconazole given in the newborn intensive care setting may prevent candidemia and colonization in high-risk patients.

Prognosis

• Prognosis for oral or cutaneous candidiasis is excellent with appropriate medical treatment.
• Systemic candidiasis, especially in low birth weight premature infants, carries a high rate of morbidity and mortality. Even with appropriate treatment, mortality may reach 50% in this population.

Patient Education

• For excellent patient education resources, visit eMedicine's Yeast and Fungal Infections Center; Children's Health Center; and Skin, Hair, and Nails Center. Also, see eMedicine's patient education articles Candidiasis (Yeast Infection), Yeast Infection Diaper Rash, and Yeast Infection Skin Rash.

MISCELLANEOUS

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Medical/Legal Pitfalls

• Candidiasis in an individual without known risk factors (eg, infant, immunocompromised state, diabetes, obesity) should prompt a search for such factors, especially immunodeficiency and HIV infection.

MULTIMEDIA

Section 10 of 11  

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Media file 1:  Typical appearance of thrush. Note multiple white plaques on lips, gingivae, tongue, and palate.
	View Full Size Image
Media type:  Photo

Media file 2:  Candidal diaper dermatitis. Note satellite papules and involvement of intertriginous folds.
	View Full Size Image
Media type:  Photo

REFERENCES

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• Crislip MA, Edwards JE Jr. Candidiasis. Infect Dis Clin North Am. Mar 1989;3(1):103-33. [Medline].
• Denning DW, Evans EG, Kibbler CC, et al. Fungal nail disease: a guide to good practice (report of a Working Group of the British Society for Medical Mycology). BMJ. Nov 11 1995;311(7015):1277-81. [Medline].
• Dodds Ashley ES, Lewis R, Lewis JS. Pharmacology of sytemic antifungal agents. Clin Infect Dis. 2006;43:S28-39.
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• Elewski BE. Cutaneous mycoses in children. Br J Dermatol. Jun 1996;134 Suppl 46:7-11: discussion 37-8. [Medline].
• Feja KN, Wu F, Roberts K, et al. Risk factors for candidemia in critically ill infants: a matched case-control study. J Pediatr. Aug 2005;147(2):156-61. [Medline].
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Article Last Updated: May 2, 2007