Guidelines for the management of candidiasis

Nosocomial Fungal Nosocomial Fungal InfectionInfection

Dr. Ajay KanthariaDr. Ajay Kantharia

M.D. M.D.• Hon. Physician & Intensivist:

• Saifee Hospital

• Sir H. N. Hospital

• Smt. Motiben B. Dalvi Hospital

Clinical Practice Guidelines for the Management

of Candidiasis:

2009 Update by the InfectiousDiseases Society of America

Candida Infection Candida Infection IntroductionIntroduction

• Candida species are the most common cause of invasive fungal infections in humans, producing infections that range from non–life-threatening mucocutaneous disorders to invasive disease that can involve any organ.

Risk FactorsRisk Factors

The most frequently implicated risk factors include the use of broad-spectrum antibacterial agents, use of central venous catheters, receipt of parenteral nutrition, receipt of renal replacement therapy by patients in ICUs, neutropenia, use of implantable prosthetic devices, and receipt of immunosuppressive agents (including

glucocorticosteroids, chemotherapeutic agents, and immunomodulators)

• Invasive candidiasis has a significant impact on patient outcomes, and it has been estimated that the attributable mortality of invasive candidiasis is as high as 47%.

Candida, where does it come from?Candida, where does it come from?


• For the most part, Candida species are confined to human and animal reservoirs; however, they are frequently recovered from the hospital environment, including on foods, counter tops, air-conditioning vents, floors, respirators, and medical personnel.


• They are also normal commensals of diseased skin and mucosal membranes of the GI, genitourinary, and respiratory tracts.

How does infection takes place ?How does infection takes place ?

• The first step in the development of a candidal infection is colonization of the mucocutaneous surfaces.

• The routes of candidal invasion are – (1) disruption of a colonized surface (skin or mucosa),

allowing the organisms access to the bloodstream, and

– (2) persorption via the GI wall, which may occur following massive colonization with large numbers of organisms that pass directly into the bloodstream.

Which systems or organs can be Which systems or organs can be involved ?involved ?


• Any system or organ can be involved.


• Cutaneous Candidiasis• Chronic Mucocutaneous candidiasis

– GI Tract• Oropharyngeal• Esophageal• Non esophageal

– Respiratory Tract• Laryngeal• Tracheobronchial• Pneumonia


– Genitourinary• Vulvovaginal• Balanitis• Cystitis• Ascending pyelonephritis


• Systemic Candidiasis– Candidemia– Disseminated Candidiasis

• Renal candidiasis• CNS infection• Arthritis, osteomyelitis• Myocarditis, Pericarditis• Peritonitis

How do we suspect Fungal How do we suspect Fungal Infection?Infection?

• High Index of suspicion is required.

• Patients who remain febrile despite broad-spectrum antibiotic therapy, with either persistent neutropenia or other risk factors and persistent leukocytosis, should be suspected of having systemic candidiasis.

Which are common Candida Which are common Candida SpeciesSpecies

• More than 100 species of Candida exist in nature; only a few species are recognized causes of disease in humans.



• The medically significant Candida species include the following: – C albicans, the most common species identified (50-60%) – Candida glabrata (15-20%) – C parapsilosis (10-20%) – Candida tropicalis (6-12%) – Candida krusei (1-3%) – Candida kefyr (<5%) – Candida guilliermondi (<5%) – Candida lusitaniae (<5%) – Candida dubliniensis, primarily recovered from patients who are

positive for HIV

Anti fungal AgentsAnti fungal Agents

• Imidazole– Miconazole– Ketoconazole– Clotrimazole

• Triazole– Posaconazole– Fluconazole– Itraconazole– Econazole, Terconazole,Tioconazole– Voriconazole, Posaconazole, Ravuconazole.

Antifungal AgentsAntifungal Agents

• Polyenes– Amphotericin B

• Antimetabolite– Flucytosine

• Echinocandins– Caspofungin– Micafungin, Anidulafungin

Basic spectrum of various Basic spectrum of various antifungalsantifungals

• Amphotericin B (AmB)• Should be considered for invasive

Candida infections caused by lesssusceptible species, such as C. glabrata and C. krusei.

L-AMB is approved for aspergillosis, candidiasis, cryptococcosis, and neutropenic patients with persistent fever on broad-spectrum antibiotics.


• Triazoles

• Fluconazole, itraconazole, voriconazole, and posaconazole demonstrate similar activity against most Candida species . Each of the azoles has less activity against C. glabrata and C. krusei.


• Fluconazole demonstrated efficacy comparable to that of AmB-d for the treatment of candidemia and is also considered to be standard therapy for oropharyngeal, esophageal, and vaginal

candidiasis


• Itraconazole is generally reserved for patients with mucosal candidiasis, especially those who have experienced treatment failure with fluconazole.


• Voriconazole is effective for both mucosal and invasive candidiasis.

• Its clinical use has been primarily for step-down oral therapy for patients with infection due to C. krusei and fluconazole-

• resistant, voriconazole-susceptible C. glabrata. CSF and vitreous penetration is excellent


• Echinocandins

• Indications are evolving and will probably include complicated forms of invasive candidiasis, candidemia, disease refractory to other systemic antifungals, and intolerance to amphotericin B. They appear to be active against all Candida species.


• Flucytosine• Flucytosine demonstrates broad antifungal

activity against most Candida species, with the exception of C. krusei.

• Flucytosine is rarely administered as a single agent but is usually given in combination with AmB for patients with invasive diseases, such as Candida endocarditis or meningitis.

Specific Candida Infection.Specific Candida Infection.

GI candidiasis

• OPC may be treated with either topical antifungal agents (eg, nystatin, clotrimazole, amphotericin B oral suspension) or systemic oral azoles (fluconazole, itraconazole).


• Candida esophagitis requires systemic therapy, usually with fluconazole or itraconazole for at least 14-21 days. Parenteral therapy with fluconazole may be required initially if the patient is unable to take oral medications.


Genitourinary tract candidiasis

• For asymptomatic candiduria, therapy generally depends on the presence or absence of an indwelling Foley catheter. The candiduria frequently resolves with changing of the Foley catheter (20-25% of patients).


• Genitourinary tract candidiasisoCandida cystitis in noncatheterized patients

should be treated with fluconazole at 200 mg/d orally for at least 10-14 days.


o The standard recommended dose for most Candida infections is fluconazole at 800 mg as the loading dose, followed by fluconazole at a dose of 400 mg/d for at least 2 weeks of therapy after a demonstrated negative blood culture result or clinical signs of improvement. This treatment regimen can be used for infections due to C albicans, C tropicalis, C parapsilosis, C kefyr, C dubliniensis, C lusitaniae, and C guilliermondi.


o Because C glabrata has lower susceptibility to antifungals, these infections require (1) higher daily doses (800 mg/d) of fluconazole, (2) caspofungin at 70 mg intravenously as a loading dose followed by 50 mg/d, (3) conventional amphotericin B (1 mg/kg/d), and (4) lipid preparations of amphotericin B at 3-5 mg/kg/d.

How do we prevent Fungal How do we prevent Fungal InfectionInfection

• Identify high risk patients

• Minimise prolonged use of antibiotics

• Recurrence of fever maybe be fungal inf

• Antifungal prophylaxsis.

• Early removal of lines

Thank youThank you

Health & Medicine

Guidelines for the management of candidiasis