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.
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.
(1,3)β-D-glucan assay is a useful nonculture method for diagnosis of invasive candidiasis. A decrease in levels during therapy has been associated with treatment success in patients on echinocandin therapy with proven invasive candidiasis. Consecutive serum measurements may be useful as prognostic markers of response. [52]
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 [29, 53] :
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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. [54]
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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. [55]
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For patients with chemotherapy-induced neutropenia, fluconazole, posaconazole, or caspofungin is recommended during induction chemotherapy for the duration of neutropenia.
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Most recent candidiasis treatment guidelines recommend prophylaxis in high-risk ICU patients in adult units that have high incidence of invasive candidiasis. [28] Oral nystatin prophylaxis has been shown to decrease colonization in ICU patients and needs to be investigated as a potential strategy to control candida-related infection in appropriately selected patients in this setting. [56]
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. [57]
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. [58, 59]
The longer the delay to initiate antifungal therapy, the higher the morbidity and mortality associated with candidemia and disseminated candidiasis.
Patient Education
Inform patients and their families about the risk factors associated with mucosal and systemic candidiasis. In addition, inform them that the systemic form of the disease is extremely serious and is associated with high morbidity and mortality rates unless aggressive action is undertaken.
For patient education resources, see Infections Center, Children's Health Center, and Skin Conditions & Beauty Center, as well as Candidiasis (Yeast Infection), Yeast Infection Diaper Rash, and Yeast Infection Skin Rash.
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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 candidiasis. Courtesy of Matthew C. Lambiase, DO.
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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.
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Dry, red, superficially scaly, pruritic macules and patches on the penis represent candidal balanitis. Courtesy of Matthew C. Lambiase, DO.
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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.
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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.
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A nailfold with candidal infection becomes erythematous, swollen, and tender with occasional discharge. Courtesy of Matthew C. Lambiase, DO.
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Soreness and cracks at the lateral angles of the mouth (angular cheilitis) are a frequent expression of candidiasis in elderly individuals. Courtesy of Matthew C. Lambiase, DO.
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Fine, superficial pustules on an erythematous patchy base are suggestive of candidiasis. Courtesy of Matthew C. Lambiase, DO.
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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.
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Candida dermatitis in the diaper area. Courtesy of Hon Pak, MD.
