Guidelines for the management of candidiasis

Dr. Ajay Kantharia 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 Infectious Diseases Society of America

Candida Infection Introduction

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 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.

Candida, where does it come from? They are also normal commensals of diseased skin and mucosal membranes of the GI, genitourinary, and respiratory tracts.

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 involved ?

Which systems or organs can be involved ? Any system or organ can be involved.

Which systems or organs can be involved ? Cutaneous Candidiasis Chronic Mucocutaneous candidiasis GI Tract Oropharyngeal Esophageal Non esophageal Respiratory Tract Laryngeal Tracheobronchial Pneumonia

Which systems or organs can be involved ? Genitourinary Vulvovaginal Balanitis Cystitis Ascending pyelonephritis

Which systems or organs can be involved ? Systemic Candidiasis Candidemia Disseminated Candidiasis Renal candidiasis CNS infection Arthritis, osteomyelitis Myocarditis, Pericarditis Peritonitis

How do we suspect Fungal 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 Species More than 100 species of Candida exist in nature; only a few species are recognized causes of disease in humans.

Which are common Candida Species

Which are common Candida Species 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 Agents Imidazole Miconazole Ketoconazole Clotrimazole Triazole Posaconazole Fluconazole Itraconazole Econazole, Terconazole,Tioconazole Voriconazole, Posaconazole, Ravuconazole.

Antifungal Agents Polyenes Amphotericin B Antimetabolite Flucytosine Echinocandins Caspofungin Micafungin, Anidulafungin

Basic spectrum of various antifungals Amphotericin B (AmB) Should be considered for invasive Candida infections caused by less susceptible 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.

Basic spectrum of various antifungals 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.

Basic spectrum of various antifungals 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

Basic spectrum of various antifungals Itraconazole is generally reserved for patients with mucosal candidiasis, especially those who have experienced treatment failure with fluconazole.

Basic spectrum of various antifungals 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

Basic spectrum of various antifungals 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.

Basic spectrum of various antifungals 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. GI candidiasis OPC may be treated with either topical antifungal agents (eg, nystatin, clotrimazole, amphotericin B oral suspension) or systemic oral azoles (fluconazole, itraconazole).

Specific Candida Infection. 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.

Specific Candida Infection. 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).

Specific Candida Infection. Genitourinary tract candidiasis Candida cystitis in noncatheterized patients should be treated with fluconazole at 200 mg/d orally for at least 10-14 days.

Specific Candida Infection. 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 .

Specific Candida Infection. 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 Infection Identify high risk patients Minimise prolonged use of antibiotics Recurrence of fever maybe be fungal inf Antifungal prophylaxsis. Early removal of lines

Guidelines for the management of candidiasis

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Guidelines for the management of candidiasis