Neobook — clinical reference

ICD-10 code: B37

Superficial and/or disseminated (systemic) fungal infection caused by C. albicans, C. tropicalis and other candida species.

Risk factors include:

Prolonged, broad-spectrum antibiotic therapy.
Compromised immune system, including patients infected with HIV or on cancer chemotherapy, and the premature baby.
Steroid therapy.
Diabetes mellitus.
IV hyperalimentation – contaminated solution or as an associated risk factor.
Instrumentation, and central or peripheral vascular catheters.

Clinical

Oral candidiasis (thrush):
- White plaque adheres to inner cheeks, lips, palate and tongue.
- Stomatitis with red mucosa and ulcers may also be present.
- In immunocompromised patients, the lesions may extend into the oesophagus.
Oesophageal candidiasis:
- Presents as difficulty swallowing, drooling or retrosternal pain (irritability in small children).
Skin lesions in the newborn:
- A red, maculopapular or pustular rash is seen in infants born to women with candida amnionitis.
Cutaneous lesions:
- May be represented by scattered, red papules or nodules.
- Superficial infections of any moist area, such as axillae or neck folds, are common and may present as an erythematous, intertriginous rash with ‘satellite’ lesions.
Vulvovaginitis:
- A thick cheesy vaginal discharge with intense pruritus; white plaques on the glans of the penis.
- Common in diabetics and patients on broad-spectrum antibiotics.
- In recurrent vulvovaginitis, exclude diabetes, foreign body or sexual abuse.
Systemic or disseminated candidiasis:
- Mimics bacterial sepsis but fails to respond to antibiotics.
- Thrombocytopenia is common.
- Ophthalmitis with ‘cotton wool’ retinal exudates may also occur.
- Is usually nosocomial.

Investigations:

For oesophageal candidiasis:
- It is reasonable to initiate treatment on clinical suspicion.
- Oesophagoscopy or barium swallow.
Systemic candidiasis:
- Urine and blood fungal cultures are essential.
- Biopsy specimens, fluid or scrapings of lesions: budding yeasts and pseudohyphae are seen on microscopy.

Encourage cup feeding of formula fed infants, as bottles are difficult to clean and predispose to candida infection.
Eradicate or minimise risk factors.
Avoid use of pacifiers (dummies), teats and bottles but if used, these should be sterilised.
Remove all invasive devices, drain abscesses and debride infected tissue.

Oral candidiasis

Nystatin suspension 100 000 IU/mL, oral, 1 mL 4 hourly.
- Keep in contact with affected areas for as long as possible.

Suspect immunodeficiency if poor response to treatment. If no response:

Oesophageal candidiasis

Fluconazole, IV/oral, 6 mg/kg immediately as a single dose.
- Follow with 3 mg/kg/day for 3 weeks.

Vulvovaginitis

Imidazole topical/vaginal, e.g.
- Clotrimazole OR miconazole, applied locally at night for 7–14 days.
  - Do not use applicator in girls who are not sexually active.

Systemic candidiasis

Amphotericin B deoxycholate, IV infusion in 5% dextrose water only, 1 mg/kg/dose once daily over 4 hours for at least 2 weeks after first negative culture, or if no repeat culture available at least 3 weeks after clinical improvement. Discuss options for de-escalation of anti-fungal treatment when sensitivity available with specialist.
- Maximum cumulative dose: 30–35 mg/kg over 4–8 weeks.
- Adjust dosing interval in patients with renal impairment.
- Check serum potassium and magnesium at least 3 times a week.
- Do not use a bacterial filter with amphotericin B deoxycholate.

Prehydration before administering amphotericin B deoxycholate to prevent renal impairment:

Sodium chloride 0.9%, IV, 15 mL/kg plus potassium chloride, 20 mmol/L infused over 2–4 hours.

Standard Treatment Guidelines and Essential Medicines List for South Africa Paediatric Hospital _2023, 5th edition_Updated July 2024

Chapter 8: Infective/Infectious Diseases, 8.6 Candidiasis, Systemic And Other

Candidiasis, Systemic and Other