Treatment Guideline Chart
Candida sp are the most common cause of fungal infections.
It can manifest from benign mucocutaneous illnesses to invasive process that may affect any organ.
It is considered as normal flora in the gastrointestinal & genitourinary tracts, but when there is an imbalance in the ecological niche they can invade & cause disease.
The immune response of the patient is the important determinant of the type of infection caused by Candida.
Most common risk factors include: prematurity, very low birth weight, use of broad-spectrum antibiotics use, use of central venous catheters, receipt of parenteral nutrition, receipt of renal placement therapy by patients in intensive care unit (ICU), neutropenia, use of implantable prosthetic devices and receipt of immunosuppressive agents.

Candidiasis%20(pediatric) Treatment

Principles of Therapy

  • General management principles that is mostly derived from adults’ candidiasis management:
    • Antifungal therapy should be administered as soon as possible
    • Ideal duration of therapy is 14 days after blood cultures are sterile
      • Longer duration may be required for candidemia with central venous catheter retention and deep-seated invasive candidiasis
    • Due to reduced susceptibility or resistance of some species to certain antifungal classes/agents, the appropriate choice of an anti-Candida agent may be influenced by local epidemiology
    • In all cases of candidemia, clinical evaluation for deep sites of infection, including ophthalmological examination is advised to be done
    • Removal or at least replacing intravenous (IV) catheters and/or other implanted prosthetic devices in a timely manner should be considered
    • Combination antifungal chemotherapy may be considered in some situations as there is no firm recommendation regarding this
  • There are limited data on dosing for antifungal agents in pediatric patients while pharmacokinetics of antifungal agents vary between adult and pediatric patients
  • In order that the most effective antifungal agent will be administered to the patient, Candida sp should be isolated and its antifungal susceptibility should be determined



  • Eg Caspofungin, Micafungin, Anidulafungin
  • For treatment of candidemia in neonates that is refractory or resistant to conventional therapy with Amphotericin B (AmB) or Fluconazole
  • United States Food and Drug Administration (US FDA) approved its use against invasive candidiasis in children
  • Not recommended for candidiasis involving the eyes, CNS, or urinary tract because of poor penetration to these sites
  • Mechanism of action: Inhibits 1,3-beta-D-glucan synthetase enzyme complex that can prevent the formation of glucan polymers (a major component of the fungal cell wall)
  • Well-tolerated with minimum adverse effects


  • Clinical use is limited; it is primarily used in combination with Amphotericin B in neonates with central nervous system candidal infections
  • Mechanism of action: Inhibits thymidylate synthetase, which disrupts DNA synthesis that is not specific to Candida sp thus there are significant side effects
  • It is discouraged to use Flucytosine in infants with very low birthweight because of poor renal function due to immaturity


  • Mechanism of action: Binds to ergosterol in the fungal cell membrane leading to cell leakage and death

Amphotericin B (AmB)

  • Eg AmB deoxycholate, liposomal AmB B, AmB lipid complex (ABLC), and AmB colloidal dispersion (ABCD)
  • AmB deoxycholate is the most commonly used antifungal agent for neonatal invasive candidiasis including disseminated neonatal candidemia as it is efficacious and well-tolerated
    • Lipid formulations are reserved for neonates who are intolerant to AmB deoxycholate but should be used with caution
  • AmB deoxycholate pharmacokinetics are highly variable in neonates and adults
  • Lipid formulations have the ability to deliver a higher dose of medication with lower levels of toxicity
  • The cost of lipid formulations and the small number of organized clinical data tend to limit use in patients at high risk of being intolerant of AmB deoxycholate
  • Nephrotoxicity (eg acute kidney injury, tubular acidosis) is the most common serious adverse effect of AmB deoxycholate
    • In contrast to older children and adults, AmB deoxycholate does not appear to be associated with risk for nephrotoxicity in neonates
  • Urinary candidiasis may be the only candidal infection where lipid-associated formulas are contraindicated


  • Used in patients with noninvasive mucocutaneous candidiasis with a low risk for disseminated systemic infection
  • Alternative prophylactic agent to Fluconazole used against invasive candidiasis in neonates with birth weights <1500 g
  • It is not absorbed systemically from the gastrointestinal tract


  • Eg Fluconazole, Voriconazole
  • Depending on the type of candidal infection, triazoles are commonly used in neonates as an alternative to AmB and in children with invasive candidiasis


  • Most commonly used triazole in neonates as an alternative to AmB and in children with invasive candidiasis
  • Recommended prophylactic agent against invasive candidiasis in neonates with extremely low birth weights (<1000 g)
  • Rapidly cleared in children; daily dose is necessary for neonates and children
  • Mechanism of action: Inhibits the fungal enzyme 14-alpha-sterol demethylase, which is necessary for the production of ergosterol, a major component of the fungal cell membrane
  • In children with neutropenia, had recent triazole use, or if Candida krusei is suspected, Fluconazole should not be used due to resistance


  • Alternative treatment for invasive candidiasis if Fluconazole is contraindicated in children
  • Not recommended for candidiasis involving the urinary tract because of poor urinary excretion

Pharmacological Therapy for Specific Type of Candidiasis
Mucocutaneous Candidiasis

Oropharyngeal Candidiasis

  • Neonates:
    • Topical Nystatin are highly effective
  • Infants:
    • Nystatin is recommended as initial treatment for immunocompetent infants
    • Oral Fluconazole may be used as an alternative to Nystatin
    • Gentian violet (0.5% or 1%) applied to the buccal mucosa once or twice daily is also effective
  • Children ≥12 months old:
    • Topical Nystatin or Clotrimazole for 7-14 days for mild oral candidiasis
    • Nystatin and Clotrimazole lozenges should not be used in children <4 years old because they are choking hazard
    • Fluconazole is indicated for moderate to severe oropharyngeal candidiasis
    • Intravenous (IV) AmB (deoxycholate or lipid formulation) or an echinocandin is the treatment for severe oropharyngeal candidiasis refractory to oral or IV Fluconazole

Diaper Dermatitis

  • Antifungal agents such as Nystatin, Clotrimazole, Miconazole, and Ketoconazole or other
  • Imidazole creams are effective topical therapies for candidal diaper dermatitis
  • Antifungal creams or ointments are applied to the diaper area beneath the barrier ointment at least two to three times a day until rash has resolved


  • The most commonly used antifungal agents are Nystatin (polyene), Miconazole, Clotrimazole, Ketoconazole, Econazole and Sertaconazole

Chronic Mucocutaneous Candidiasis

  • The preferred treatment is Fluconazole or Itraconazole

Invasive Candidiasis


  • There is a high likelihood of disseminated disease and the possibility of infection within the CNS thus treatment is complicated
  • The following can be potentially used for treatment: AmB deoxycholate, liposomal AmB, AmB lipid complex, Fluconazole, Micafungin and Caspofungin
  • AmB is recommended as first line treatment while Fluconazole as the alternative 1st-line agent


  • With several exceptions, recommendations for the treatment are extrapolated from the adult studies, with concomitant pharmacokinetic studies
  • AmB deoxycholate, liposomal AmB, AmB lipid complex, Micafungin, Caspofungin, Anidulafungin, Fluconazole, and Voriconazole can all be used
  • Echinocandins are the 1st-line agents for the treatment of invasive candidiasis in children
  • Liposomal AmB is an alternative 1st-line agent

Non-Pharmacological Therapy

Remove Possible Source of Infection

  • Existing central venous catheters or bladder catheter, or infected CNS devices (eg ventriculostomy drains and shunts) should be removed, when feasible
  • Intravascular catheter removal is strongly recommended
  • Removal of urinary tract instruments, including stents and Foley catheters, is often helpful
  • If complete removal is not possible, placement of new devices may be beneficial

Sterilization or Decolonization

  • Measures to prevent reinfection include sterilization or decolonization of items and body sites that are placed in the infant’s mouth
    • Bottle nipples and pacifiers that are to be reused should be boiled after each use
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