These results are supported by anecdotal reports [ ]. Early aggressive therapy is critically important. Delays in diagnosis may lead to loss of vision. Given the devastating consequences associated with loss of sight, aggressive therapy is warranted. All patients with candidemia should have at least 1 dilated retinal examination, preferably by an ophthalmologist A-II. The preponderance of clinical experience of treatment is with amphotericin B, often combined with flucytosine B-III. Recent data also support the use of fluconazole for this indication, particularly as follow-up therapy B-III.
Use of the maximal doses appropriate for other forms of invasive candidiasis would be appropriate to maximize penetration into the eye. Therapy should be continued until complete resolution of visible disease or convincing stabilization.
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Courses of 6—12 weeks of therapy are typically required. A diagnostic vitreal aspirate is generally recommended for patients presenting with endophthalmitis of unknown origin.
If fungal elements are observed, some ophthalmologists instill intravitreal amphotericin B deoxycholate therapy. The utility of vitrectomy has not been systematically studied. Extrapolation from a study of bacterial endophthalmitis [ ] and from anecdotal experiences with Candida endophthalmitis [ ] suggests that initial vitrectomy and intravitreal amphotericin B therapy may be most appropriate for patients with substantial vision loss.
To eliminate signs and symptoms of the disease and to prevent recurrences.
Topical azoles clotrimazole troches , oral azoles fluconazole, ketoconazole, or itraconazole , or oral polyenes such as nystatin or oral amphotericin B are usually effective treatments for oropharyngeal candidiasis. For refractory or recurrent infections, orally administered and absorbed azoles ketoconazole, fluconazole, or itraconazole solution , amphotericin B suspension, intravenous caspofungin, or intravenous amphotericin B only for otherwise unresponsive infections may be used. For treatment of esophageal candidiasis, topical therapy is ineffective.
Azoles fluconazole, itraconazole solution, or voriconazole , intravenous caspofungin, and intravenous amphotericin B necessary only for otherwise unresponsive infections are effective. Multiple randomized prospective studies of oropharyngeal candidiasis have been performed in patients with AIDS and patients with cancer. Most patients respond initially to topical therapy [ — ]. In HIV-infected patients, symptomatic relapses may occur sooner with topical therapy than with fluconazole [ ], and resistance may develop with either regimen [ ].
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Fluconazole is superior to ketoconazole [ ]. Itraconazole capsules are equivalent in efficacy to ketoconazole [ ]. Itraconazole solution is better absorbed than the capsules [ ] and is comparable in efficacy to fluconazole [ — ]. A dosage of itraconazole solution of 2. Topical effects of oral solutions may be as important as effects due to absorption [ , ]. Recurrent infections typically occur in patients with immunosuppression, especially AIDS.
Long-term suppressive therapy with fluconazole is effective in the prevention of oropharyngeal candidiasis in patients with AIDS [ 32 , — ] and patients with cancer [ ]. Long-term suppressive therapy with fluconazole in HIV-infected patients has been shown to reduce the incidence of invasive fungal infections but has no effect on overall survival [ 32 , — ].
In a recent large study, long-term suppressive therapy with fluconazole was compared with episodic use of fluconazole in response to symptomatic mucosal disease. Continuous suppressive therapy reduced the relapse rate relative to intermittent therapy and was associated with an increased rate of development of in vitro microbiological resistance, but the frequency of clinically refractory disease was the same for the 2 study groups [ ]. Oral polyenes, such as amphotericin B or nystatin, are less effective than fluconazole in preventing this infection [ ]. Intravenous caspofungin is a reasonable alternative [ 58 ].
Oral or intravenous amphotericin B is also effective in some patients [ ]. Itraconazole oral solution has also proven to be effective in cases of fluconazole-refractory oral candidiasis [ — ].
Oral solution of amphotericin B has also been successfully used to treat fluconazole-resistant thrush [ ]. Much of the information on the microbiology of esophageal candidiasis is extrapolated from studies of oropharyngeal candidiasis. The presence of oropharyngeal candidiasis and symptoms of esophagitis i. A therapeutic trial with fluconazole for patients with presumed esophageal candidiasis is a cost-effective alternative to endoscopy; most patients with esophageal candidiasis will have resolution of their symptoms within 7 days after the start of therapy [ ].
Fluconazole is superior to ketoconazole, itraconazole capsules, and flucytosine for the treatment of esophageal candidiasis [ — ]. Itraconazole capsules plus flucytosine are as effective as fluconazole [ ]. The efficacy of itraconazole solution has been shown to comparable to that of fluconazole [ ]. Voriconazole mg b. Voriconazole has shown success in treatment of cases of fluconazole-refractory disease [ 48 ]. Intravenous amphotericin B is also effective [ ]. Caspofungin acetate has shown activity and safety equivalent to fluconazole [ 58—60 ], including good responses in individuals with fluconazole-refractory disease [ 61 ].
In cases of both oropharyngeal and esophageal candidiasis, the vast majority of infections are caused by C. However, symptomatic infections caused by C. A large randomized trial performed during the HAART era found that the rate of development of clinical fluconazole resistance was the same for individuals receiving long-term suppressive therapy as for those receiving episodic intermittent therapy [ ], even though the Candida isolates recovered from the patients receiving continuous therapy showed reduced susceptibility to fluconazole. Antifungal susceptibility testing has been shown to be predictive of clinical response to fluconazole and itraconazole [ 30 ].
The symptoms associated with oropharyngeal and esophageal candidiasis may reduce oral intake of food and liquids and may significantly reduce the quality of life. Maintenance of adequate nutrition and hydration is essential for immunocompromised hosts. Many individuals have asymptomatic oropharyngeal colonization with Candida species, and treatment frequently does not result in microbiological cure.
Therefore, oropharyngeal fungal cultures are of little benefit. Multiple courses of therapy or the use of suppressive therapy for recurrent infection are major risk factors for the development of an azole-refractory infection. Ketoconazole and itraconazole capsules are less effective than fluconazole, because of variable absorption A-I. Patients tolerate repeated episodes of oropharyngeal candidiasis without difficulty, especially if the episodes occur infrequently A-I. Suppressive therapy is effective for preventing recurrent infections A-I.
Although it does the increase the rate of development of isolates with an increased fluconazole MIC, the use of continuous suppression rather than episodic or intermittent therapy in response to symptomatic relapse does not increase the likelihood of developing an infection that fails to respond to fluconazole A-I. An oral suspension of amphotericin B 1 mL q.
There have also been anecdotal reports of responses of refractory disease to use of fluconazole solution used in a swish-and-swallow fashion [ ] and to use of chewed itraconazole capsules. Denture-related disease may require extensive and aggressive disinfection of the denture for definitive cure [ — ]. Systemic therapy is required for effective treatment of esophageal candidiasis B-II. Although symptoms of esophageal candidiasis may be mimicked by other pathogens, a diagnostic trial of antifungal therapy is often appropriate before performing endoscopy B-II.
Voriconazole is as effective as fluconazole but is associated with more adverse events A-I. Suppressive therapy may be used for patients with disabling recurrent infections A-II. Intravenous amphotericin B deoxycholate 0. Antifungal susceptibility testing is not generally needed for the management of either oropharyngeal or esophageal candidiasis, but can be useful in patients with refractory infection B-II. Whereas onychomycosis is usually caused by a dermatophyte, infections due to Candida species also occur [ ]. Topical agents are usually ineffective [ ].
For onychomycosis, oral griseofulvin has largely been replaced by more-effective agents, including oral terbinafine or itraconazole [ ].
With respect to Candida onychomycosis, terbinafine has only limited and unpredictable in vitro activity [ , ] and has not demonstrated consistently good activity in clinical trials [ ]. Although the number of reported cases is small, therapy with itraconazole does appear to be effective [ , ]. Itraconazole mg b.
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Nonhematogenous primary skin infections typically occur as intertrigo in skin folds, especially in obese and diabetic patients. Topical azoles and polyenes, including clotrimazole, miconazole, and nystatin, are effective. Keeping the infected area dry is important.
For paronychia, the most important intervention is drainage. Although a clear association remains to be determined, because of the lack of application of consistent clinical and microbiological criteria, nipple or breast pain in nursing mothers has been linked to the presence of C.
Nursing worsens or precipitates the pain. Classical findings of mastitis are absent, as is fever, and the findings of a local physical examination are often unimpressive [ ].
The infant may or may not have signs of mucosal or cutaneous candidiasis. Microbiological studies have found both bacteria [ , ] and C. The true cause of the pain associated with this syndrome is unclear, but treatment of the mother and the infant with an antifungal agent has produced relief, according to some reports [ , ]. Optimal diagnostic criteria and management strategies are not certain, but both topical nystatin and oral fluconazole are safe for infants [ — ] and could be considered as therapy for mother and child if the presentation is strongly suggestive of candidiasis.
The persistent immunological defect associated with chronic mucocutaneous candidiasis requires a long-term approach that is analogous to that used in patients with AIDS and rapidly relapsing oropharyngeal candidiasis [ ]. Systemic therapy is needed, and all of the azole antifungal agents ketoconazole, fluconazole, and itraconazole have been used successfully [ , ]. The required dosages are similar to those used for other forms of mucocutaneous candidiasis. As with HIV-infected patients, development of resistance to these agents has also been described [ , ].
To achieve rapid and complete relief of signs and symptoms of vulvovaginal inflammation, along with prevention of future recurrences. Topical agents including azoles all are used for 1—7 days depending on risk classification: over-the-counter [OTC] clotrimazole, OTC butoconazole, OTC miconazole, OTC tioconazole, terconazole , nystatin [, U per day for 7—14 days], oral azoles ketoconazole [ mg b.
Boric acid administered vaginally mg gelatin capsule, once per day for 14 days is also effective [ ]. Resolution of signs and symptoms of vaginitis 48—72 h after initiation of therapy, and mycological cure 4—7 days after initiation of therapy. Multiple double-blind randomized studies [ , , ]. Highly effective relief of symptoms that are associated with substantial morbidity can be achieved promptly with current therapies. Self-diagnosis of yeast vaginitis is unreliable. Incorrect diagnosis results in overuse of topical antifungal agents, with subsequent risk of contact and irritant vulvar dermatitis.