eMedicine Specialties > Infectious Diseases > Fungal Infections

Candidiasis: Follow-up

Author: Jose A Hidalgo, MD, Assistant Professor, Universidad de San Marcos Medical School; Attending Physician, Department of Internal Medicine, Division of Infectious Diseases, Guillermo Almenara Hospital
Coauthor(s): Jose A Vazquez, MD, FACP, FIDSA, Consulting Staff, Division of Infectious Diseases, Henry Ford Hospital; Professor, Department of Internal Medicine, Wayne State University School of Medicine
Contributor Information and Disclosures

Updated: Jan 11, 2010

Follow-up

Further Inpatient Care

  • Inpatient care is frequently prolonged because of the severe nature of the disseminated infections.
  • Antifungal therapy may be necessary for a prolonged period, either parenterally or orally.

Further Outpatient Care

  • Mucocutaneous candidiasis
    • Patients treated in the outpatient area may be discharged home with medications. Instruct patients to follow up if the symptoms persist or worsen.
    • If the infections are recurrent, perform an HIV antibody test and rule out conditions that produce immune suppression, such as hematologic malignancies, solid organ malignancy, and diabetes mellitus. If no etiology is established, refer the patients for consultation with an infectious disease specialist to rule out an underlying immune deficiency.
  • Candidemia and disseminated candidiasis
    • Because of the severity of the infections, some patients may remain hospitalized for a prolonged period.
    • Patients on outpatient amphotericin B must be monitored 2-3 times weekly because of its high incidence of adverse effects. The parameters that need to be monitored include CBC count with differentials; electrolyte evaluations; and serum magnesium, BUN, and serum creatinine levels.

Inpatient & Outpatient Medications

  • With newer treatment modalities that have been recently instituted, de-escalation of antifungal therapy or the rapid switch from intravenous to oral administration is encouraged. Recent clinical studies suggest that patients who are clinically stable and have a functional gastrointestinal tract on day 4-5 of parenteral intravenous antifungal administration should be switched from intravenous to oral therapy with either fluconazole or voriconazole.
  • Although relatively uncommon, patients may be discharged home on parenteral antifungal therapy or oral azole therapy with close monitoring for toxicity.

Transfer

  • Transfer patients to the service that can care for the specific candidal infections (eg, general surgery, ICU).
  • Transfer patients with sepsis or altered mental status to an appropriate critical care unit.

Deterrence/Prevention

  • Antifungal prophylaxis of invasive candidiasis in high-risk patients is currently recommended for the following:21,39
    • Stem cell transplant recipients, primarily those with allogeneic transplants, are recommended to receive fluconazole initiated 1 day prior to neutropenia and continued until neutropenia resolves. Micafungin and posaconazole are also recommended for this indication.40
    • Solid organ transplant recipients may be considered for antifungal prophylaxis with fluconazole or liposomal amphotericin B for the prevention of candidiasis. This is recommended for postoperative antifungal prophylaxis in liver, pancreas, and small bowel transplant recipients at high risk of candidiasis. Additional indications are being investigated.41
    • For patients with chemotherapy-induced neutropenia, fluconazole, posaconazole, or caspofungin is recommended during induction chemotherapy for the duration of neutropenia.
    • Most recent candidiasis treatment guidelines recommend prophylaxis in high-risk ICU patients in adult units that have high incidence of invasive candidiasis.21
  • Currently, no strong indications exist for primary or secondary prevention of oropharyngeal candidiasis (OPC) or vaginal candidiasis in patients infected with HIV. However, concern does exist about the potential development of resistance or colonization by resistant species or strains of Candida. Prophylaxis may be indicated in a select group of patients with recurrent symptomatic candidiasis.
  • Control the blood glucose level in patients with diabetes mellitus.
  • Eliminate or decrease risk factors such as steroids, cyclosporin, and tacrolimus.
  • Nosocomial candidemia prevention should be based on hand hygiene, optimal catheter care, and prudent antimicrobial use.42

Complications

  • If left untreated, candidemia can lead to metastatic foci of infection in the eyes, vertebral column, liver, spleen, CNS, and kidneys. Initiate prompt treatment to prevent foci of infection, abscess formation, and death.

Prognosis

  • Prognosis depends on several factors, such as the site of infection, the degree and type of immunosuppression, and the rapidity of diagnosis and treatment.
  • Mucocutaneous candidiasis carries an excellent prognosis, with no mortality and only minimal morbidity.
  • Systemic candidiasis carries a mortality rate of 30-40% and is generally correlated with the degree of immunosuppression and the underlying disease. In certain groups of patients, the presentation of Candida infection increases the likelihood of death, lengthens hospital stays, and increases hospitalization costs.43,44
  • The longer the delay to initiate antifungal therapy, the higher the morbidity and mortality associated with candidemia and disseminated candidiasis.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Missing a critical diagnosis may lead to potential legal disputes due to the high rates of morbidity and mortality associated with systemic candidiasis.
  • A positive blood culture result for a Candida species essentially mandates systemic antifungal therapy to prevent serious sequelae of untreated disease.
  • A major pitfall may be in establishing a definitive diagnosis of disseminated candidiasis in the setting of negative blood culture results. Strongly consider the initiation of empiric antifungal therapy if one of the following occurs:
    • The patient has risk factors for candidiasis.
    • The patient is febrile and on broad-spectrum antibiotics.
    • The patient is colonized by Candida species.
 


More on Candidiasis

Overview: Candidiasis
Differential Diagnoses & Workup: Candidiasis
Treatment & Medication: Candidiasis
Follow-up: Candidiasis
Multimedia: Candidiasis
References
Further Reading
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References

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Further Reading

Bodey GP (Ed). Candidiasis. Pathogenesis, diagnosis and treatment. 2nd ed. New York, NY; Raven Press; 1993.

Calderone RA (Ed). Candida and candidiasis. Washington, DC; ASM Press; 2002.

NCCLS. Method for Antifungal Disk Diffusion Susceptibility Testing of Yeasts; Proposed Guideline. NCCLS document M44-P [ISBN 1-56238-488-0]. NCCLS, Pennsylvania, USA 2003

NCCLS. Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts; Approved Standard-Second Edition. NCCLS document M27-A2 [ISBN 1-56238-469-4]. NCCLS, Pennsylvania, USA 2002.

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Keywords

candidiasis, Candida albicans, C albicans, fungal infection, candidal infection, candidosis, fungus infection, Candida, mucocutaneous candidiasis, candidemia, disseminated candidiasis, candidal colonization, candidiasis syndromes, intertrigo, paronychia, onychomycosis, oral thrush, mucosal candidiasis, systemic candidiasis, hepatosplenic candidiasis, fungemia, granulocytopenia, oropharyngeal candidiasis, OPC esophageal candidiasis, vulvovaginal candidiasis, VVC, cutaneous candidiasis syndromes, chronic mucocutaneous candidiasis

Addison disease, membranous candidiasis, erythematous candidiasis, chronic atrophic candidiasis, nonesophageal gastrointestinal candidiasis, respiratory tract candidiasis, laryngeal candidiasis, genitourinary tract candidiasis, candidal endophthalmitis, intravascular catheter-related candidiasis, fungal endocarditis, renal candidiasis, Candida peritonitis, Candida esophagitis, Candida folliculitis, Candida balanitis, Candida cystitis, Candida tracheobronchitis, Candida pneumonia, Candida splenic abscess, Candida hypersplenism
Candida cholecystitis, Candida arthritis, Candida osteomyelitis, Candida costochondritis, Candida myositis, Candida myocarditis-pericarditis, Candida endocarditis fungal meningitis, Candida parapsilosis , C parapsilosis, Candida glabrata , C glabrata, Candida tropicalis , C tropicalis
Candida krusei , C krusei, Candida kefyr, C kefyr, Candida dubliniensis , C dubliniensis, Candida guilliermondi , C guilliermondi, Candida lusitaniae , C lusitaniae

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Contributor Information and Disclosures

Author

Jose A Hidalgo, MD, Assistant Professor, Universidad de San Marcos Medical School; Attending Physician, Department of Internal Medicine, Division of Infectious Diseases, Guillermo Almenara Hospital
Jose A Hidalgo, MD is a member of the following medical societies: HIV Medicine Association of America and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Jose A Vazquez, MD, FACP, FIDSA, Consulting Staff, Division of Infectious Diseases, Henry Ford Hospital; Professor, Department of Internal Medicine, Wayne State University School of Medicine
Jose A Vazquez, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Society for Microbiology, Infectious Diseases Society of America, International Immunocompromised Host Society, and Medical Mycology Society of the Americas
Disclosure: pfizer Grant/research funds Independent contractor; Johnson & Johnson Grant/research funds Independent contractor; Schering Plough Grant/research funds Independent contractor; Merck Grant/research funds Independent contractor; Pfizer Honoraria Speaking and teaching; Basilea Grant/research funds Independent contractor

Medical Editor

David Hall Shepp, MD, Program Director, Fellowship in Infectious Diseases, Department of Medicine, North Shore University Hospital; Associate Professor, New York University School of Medicine
David Hall Shepp, MD is a member of the following medical societies: Infectious Diseases Society of America
Disclosure: Gilead Sciences Salary Management position

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Ronald A Greenfield, MD, Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist  Speaking and teaching

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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