Candidiasis Treatment

• When choosing an antifungal agent, consider the following factors:
  • Patient’s clinical status
  • Physician’s knowledge of the species and/or antifungal susceptibility of the infecting isolate
  • Relative drug toxicity
  • Presence of organ dysfunction that would affect drug clearance
  • Available knowledge of use of the drug in the given patient population
  • Patient’s prior exposure to antifungal agents

• Premature discontinuation of antifungal therapy may lead to recurrent infection
• Treatment duration depends on extent of involved organs
  • In patients with documented candidemia, duration of therapy with systemic antifungal agents should be 14 days after the first negative blood culture
  • Oral therapy may start after 10 days of intravenous (IV) therapy

• Eg Anidulafungin, Caspofungin, Micafungin
• Alternative agents for patients with oropharyngeal or esophageal candidiasis unresponsive to azole therapy
• With low minimum inhibitory concentrations for Candida sp, which provides good efficacy against esophageal and invasive candidiasis with less adverse events
• Preferred empiric treatment in non-neutropenic intensive care unit (ICU) patients suspected with candidiasis and patients requiring intravenous therapy
• Caspofungin requires dosage reduction for moderate to severe hepatic dysfunction

• Has broad antifungal activity against most Candida species with the exception of Candida krusei
• Primarily used in combination with Amphotericin B (AmB) with more refractory infections such as Candida endocarditis, meningitis and endophthalmitis, and Fluconazole-resistant Candida glabrata vulvovaginal candidiasis
• Occasionally used for symptomatic urinary tract candidiasis due to Fluconazole-resistant C glabrata

• Eg Clotrimazole, Miconazole
• Preferred topical therapy for mild oropharyngeal candidiasis and vulvovaginal candidiasis

• Efficacious for Candida but has well-documented significant toxicity
• Lipid formulations [eg Amphotericin B lipid complex (ABLC), Amphotericin B colloidal dispersion (ABCD), liposomal AmB] are less toxic but as effective as Amphotericin B deoxycholate (AmB-d) when used in appropriate dosages
• Treatment alternative for patients with Fluconazole-refractory oropharyngeal or esophageal candidiasis
• Topical formulation when combined with Flucytosine cream is used as an alternative treatment option against C glabrata infection
• Urinary candidiasis may be the only candidal infection where lipid-associated formulas are contraindicated
  • It is theorized that the lipid-associated formulas will potentially reduce delivery of AmB and thus slow the pace of response
• Used as alternative treatment in patients who are intolerant with other antifungal agents

• Preferred topical therapy for mild oropharyngeal candidiasis
• May cause dental caries when used over a prolonged period of time

• Preferred initial therapy for most adult patients with candidiasis
• Highly effective for the treatment of superficial and invasive candidal infections
• Oral Fluconazole is recommended in patients with moderate to severe oropharyngeal candidiasis, especially those who are unable to apply topical agents, with high aspiration risk, or in immunocompromised patients at risk for disseminated disease, and vulvovaginal candidiasis
• Oral or IV Fluconazole is the preferred treatment for patients with esophageal candidiasis
• Inferior to Anidulafungin but better than echinocandins against Candida parapsilosis
• Used as an alternative treatment for patients with no recent exposure to azole and those who are not colonized by azole-resistant Candida sp
• Recommended chronic suppressive therapy for patients with recurrent esophageal, vulvovaginal or oropharyngeal candidiasis

• Recently approved expanded-spectrum triazole with good in vitro activity against Candida sp
• Alternative treatment option to Fluconazole against uncomplicated esophageal candidiasis
• It is suggested by preliminary analysis of the recently completed international double-blind trial that Isavuconazole did not meet criteria for noninferiority when compared to an echinocandin

• A useful agent for dermatologic and mucosal candidal infections but its role in invasive candidal infections has yet to be determined

Oteseconazole

• May be considered in patients with recurrent vulvovaginal candidiasis who are not of reproductive potential

• Alternative treatment for Fluconazole-refractory oropharyngeal and esophageal candidiasis 
• Alternative suppressive therapy for patients with recurrent esophageal candidiasis

• As active as Fluconazole against esophageal candidiasis
• Used for mucosal and invasive candidiasis as step-down oral therapy in patients with candidal infection caused by C krusei and Fluconazole-resistant, Voriconazole-susceptible C glabrata
• Should not be used for urinary candidiasis as it does not accumulate in active form in the urine

• Topical gentian violet may be considered for mild oropharyngeal candidiasis

• Dentures should be removed, brushed thoroughly, and soaked in antiseptic solution before going to bed