RISK FACTORS: Immunosuppression, Antibacterial therapy, Douching and other intravaginal chemicals, Other vaginitides, Dentures, Chronic steroids (oral or inhaled), Hyperglycemia,
Exogenous estrogen, Other immunosuppressive disorders/leukopenias
GENERAL MEASURES : Screen both well infants and patients with severe immunodefi ciency using
appropriate history and physical at all routine visits
DRUG(S) OF CHOICE :
. VAGINAL (one day therapies): . Fluconazole (Difl ucan) 150mg tablet once
. Clotrimazole (Canesten) 500mg (intravaginal) tablet
. Tioconazole (Monistat-1, Vagistat-1) 6.5% ointment 5 grams
. Butoconazole (Femstat, Gynazole-1) 2% cream 5 grams
. Vaginal (conventional multi-day therapies): . Miconazole (Monistat) 2% cream: one applicator or 100 mg suppositories, intravaginally q hs x 7 days
. Clotrimazole (Gyne-Lotrimin, Mycelex): intravaginal suppositories 100 mg q hs x 6-7 days or 200 mg q hs x 3 days. 1% cream one applicator intravaginally q hs x 6-7 days.
. Nystatin (Mycostatin, Nilstat) 100,000 U/gram cream (one applicator) or 100,000 U tablets (one) intravaginally bid x 7 days
. OROPHARYNGEAL: Clotrimazole (Mycelex) 10 mg troche, slowly dissolve in mouth 5 times per day, preferably over 20 minutes for 7-14 days (2 days after disappearance of thrush) (first choice in most literature)
. Nystatin pastilles - 1 or 2, qid for 7-14 days (2 days after disappearance of thrush)
. Nystatin oral suspension (100,000 units/mL): Children apply 5-10 mL qid x10 days directly to oral lesions.
Adults swish and swallow 5-10 mL over 20 minutes qid x14 days. Prophylaxis for relapses consists of above dosages 2-5 times per day.
. Fluconazole 100mg qd for 7-14 days
. ESOPHAGITIS:
. Fluconazole (Diflucan) 200 mg, then 100 mg po qd x10-21 days
. Itraconazole solution 100-200 mg/day for 14-21 days
. Ketoconazole (Nizoral) 200-400 mg tablets - one po qd x14-21 days
. GASTROINTESTINAL (therapy not well defined) :
. Fluconazole 200 mg tablets - one po qd x14-21 days
. Amphotericin B (Fungizone) IV
β’ Note: Resistant candidiasis is common in severely immunocompromised hosts. Some patients with otherwise
resistant oropharyngeal and/or esophageal infection benefit from amphotericin B, 50 mg 3 times a week or
from itraconazole (Sporanox) 200 mg bid for the same number of days described under fl uconazole dosing for
the various sites of infection mentioned above.
PRECAUTIONS :
β’ Vaginal - miconazole is usually drug of choice in pregnancy
β’ Ketoconazole - rarely, men may have difficulty achieving erections secondary to this drug. May cause light
sensitivity. Teratogen in pregnancy and probably excreted in milk. Not well studied in children. Anaphylaxis
is reported. Hepatic toxicity has been noted, predominantly with long-term therapy.
β’ Fluconazole - adjust dose with renal compromise. Hepatotoxicity is rare. Very expensive relative to most other oral agents. Resistance has often been noted.
β’ Itraconazole - doubling the Itraconazole dose results in approximately a three-fold increase in the itraconazole plasma concentrations
β’ Amphotericin B - renal toxicity and hypokalemia common. Careful monitoring is mandatory. Ketotic diabetics
should have well controlled blood sugars prior to administration. Safety during pregnancy is not established.
ALTERNATIVE DRUGS:
. VAGINAL :
. Terconazole (Terazol) particularly for recurrent cases that may involve imidazole resistance. 0.4% cream
- one applicator intravaginally q hs x 7 days; 0.8% cream/80 mg suppositories - one applicator or one
suppository intravaginally q hs x 3 days
. Any of the antifungal creams or suppositories can be tried every month for a few days near menses to help
curb recurrent infections
. OROPHARYNGEAL :l
. Ketoconazole 200-400 mg po qd x 14-21 days
. Fluconazole 50-200 mg tablets - one po qd x 14-21 days, although a majority of fungal strains found in
the oropharynx are likely to be resistant
. ESOPHAGITIS :
. Amphotericin B (variable dosing)
PATIENT MONITORING : Immunocompromised persons may need to monitor themselves regularly. Use symptoms to monitor as well as routine KOH preps and or visual investigations during vaginal or oral exams.
PREVENTION/AVOIDANCE:
β’ Antibiotics can potentiate candidiasis
β’ Candida overgrowth is more likely with pH changes from douching, chemicals (such as spermicides) or
other vaginitides
β’ Moist environments are conducive to overgrowth of Candida . Cotton underwear may help deter some
Candida infections.
POSSIBLE COMPLICATIONS:
β’ Rarely develops major complications in immunocompetent persons
β’ With immunocompromised, generally depends on severity of immune status (CD4 count is the most common marker). Moderate immunodepression (CD4 200-500) may be associated with chronic candidiasis. With severe immunodepression (CD4 < 100) thrush can lead to esophagitis and, later, a full systemic infection
can involve every organ system, particularly the kidney (candiduria).
EXPECTED COURSE/PROGNOSIS:
β’ For immunocompetent individuals, a benign course and excellent prognosis is the norm
β’ In immunosuppressed persons, Candida may become an AIDS defining illness by CDC criteria and
chronicity can cause much morbidity and, less commonly, mortality