Candidiasis Follow-up

  • Author: Jose A Hidalgo, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Oct 27, 2011
 

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.
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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.
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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.
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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.
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Deterrence/Prevention

  • Antifungal prophylaxis of invasive candidiasis in high-risk patients is currently recommended for the following:[21, 40]
    • 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.[41]
    • 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.[42]
    • 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.[43]
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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.
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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.[44, 45]
  • The longer the delay to initiate antifungal therapy, the higher the morbidity and mortality associated with candidemia and disseminated candidiasis.
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Patient Education

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Contributor Information and Disclosures
Author

Jose A Hidalgo, MD  Assistant Professor, Universidad Nacional Mayor de San Marcos; Attending Physician, Department of Internal Medicine, Division of Infectious Diseases, Guillermo Almenara Hospital, Peru

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; Merck Grant/research funds Independent contractor; Pfizer Honoraria Speaking and teaching; Astellas Grant/research funds Independent contractor; Strativa Honoraria Speaking and teaching

Specialty Editor Board

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

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Ronald A Greenfield, MD  Professor, Department of Internal Medicine, 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; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist Honoraria Speaking and teaching; Forest Pharmaceuticals Speaking and teaching

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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A moist, erosive, pruritic patch of perianal skin and perineum (with satellite pustule formation) is demonstrated in this woman with extensive candidosis. Courtesy of Matthew C. Lambiase, DO.
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. Courtesy of Matthew C. Lambiase, DO.
Dry, red, superficially scaly, pruritic macules and patches on the penis represent candidal balanitis. Courtesy of Matthew C. Lambiase, DO.
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. Courtesy of Matthew C. Lambiase, DO.
Erythema, maceration, and satellite pustules in the axilla, accompanied by soreness and pruritus, result in a form of intertrigo. Courtesy of Matthew C. Lambiase, DO.
A nailfold with candidal infection becomes erythematous, swollen, and tender with occasional discharge. Courtesy of Matthew C. Lambiase, DO.
Soreness and cracks at the lateral angles of the mouth (angular cheilitis) are a frequent expression of candidosis in elderly individuals. Courtesy of Matthew C. Lambiase, DO.
Fine, superficial pustules on an erythematous patchy base are suggestive of candidosis. Courtesy of Matthew C. Lambiase, DO.
Candidal infection should be in the differential diagnosis when one or more nails become discolored, have subungual discoloration, have nailplate separation from the nailbed, and lack evidence of a dermatophyte. Courtesy of Matthew C. Lambiase, DO.
Candida dermatitis in the diaper area. Courtesy of Hon Pak, MD.
 
 
 
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