Treatment: Candidiasis

• Mucocutaneous candidiasis: Azoles are preferred; nystatin is an alternative.
  • - Topical applications are appropriate when possible.
  • - Oral therapy can be used for vulvovaginal infections (fluconazole, 150 mg PO as a single dose) and esophageal infections (fluconazole, 100-200 mg/d; or itraconazole, 200 mg/d).
• Candidemia and suspected disseminated candidiasis: All pts with candidemia should be treated with a systemic antifungal agent for at least 2 weeks after the last positive blood culture.
  • - Lipid formulations of AmB, echinocandins, and fluconazole or voriconazole are all effective; no agent within a given class is clearly superior to the others.
  • - The choice of antifungal drug depends on local epidemiology and susceptibility profiles.
  • - Neutropenic or hemodynamically unstable pts should be treated with broader-spectrum agents (e.g., AmB, echinocandins) until the pathogen is specifically identified and a clinical response assessed.
  • - Fluconazole is preferred for nonneutropenic, hemodynamically stable pts when azole resistance is not considered likely.
  • - When possible, foreign materials (e.g., catheters) should be removed or replaced.
  • - All pts with candidemia should undergo an ophthalmologic examination because of high rates of Candida endophthalmitis, which may require partial vitrectomy.
  • - Candida endocarditis should be treated with valve removal and long-term antifungal administration (see Chap. 80. Infective Endocarditis).
  • - Candida meningitis is often treated with a polyene plus flucytosine (25 mg/kg qid).
  • - Successful treatment of Candida-infected prosthetic material (e.g., an artificial joint) nearly always requires removal of the infected material followed by long-term antifungal therapy.