Candidiasis

Question 1

asymptomatic candiduria in usually well diabetic patient. No planned urological procedure/neutropenia. How to manage?

Answer 1

no antifungal needed. removal of catheter should suffice.

Question 2

Neutropenic pt with asymptomatic candiduria. how to manage?

Answer 2

If neutropenic/low birth weight, treat as for candidaemia.

Question 3

Well patient about to undergo urological manipulation. found to have asymptomatic candiduria. How to treat?

Answer 3

Give PO fluconazole 400mg/kg daily few days before and after procedure.

Question 4

Patient with symptomatic candida cystitis. Candida sp. fluconazole-sensitive. How to treat?

Answer 4

give po fluconazole 200mg OD for 2 weeks.

Question 5

pt with symptomatic candida cystitis. grew C.krusei/ fluconazole-R C.glabrata. How to treat?

Answer 5

Ambisome 7 days

consider bladder irrigation with AmB 5mg/L daily for 5 days

Question 6

pt with candida pyelonephritis. Candida sp. fluconazole-sensitive.

how to treat?

Answer 6

as per symptomatic candiduria.

fluconazole 200mg po daily for 2 weeks.

Question 7

pt with candida pyelonephritis. grew C.krusei/ fluconazole-R C.glabrata. How to treat?

Answer 7

as per fluconazole-R symptomatic candiduria.

Ambisome 7 days

Question 8

Candida urine infection with fungus ball. How to manage?

Answer 8

1. Surgery
2. Antifungal as per symptomatic cystitis/pyelonephritis
3. if got nephrostomy tube, irrigate

Question 9

How to manage candida vulvovaginitis

• moderate?
• severe acute?

Answer 9

moderate: po fluconazole 150mg stat

severe acute: po fluconazole 150mg stat every 72 hours, for 3 doses

Question 10

candida esophagitis. How to manage?

Answer 10

PO fluconazole 400mg od for 2-3 weeks

Question 11

How to manage esophageal candida refractory to fluconazole?

give oral and iv option.

Answer 11

oral: itraconazole solution 200mg od or voriconazole 200mg bd

IV: echinocandin/ambisome

duration 2-3 weeks as per fluconazole-sensitive eosophageal candida

Question 12

How to manage oropharyngeal candidiasis?

mild disease-

moderate-severe disease -

refractory disease -

chronic recurrent -

Answer 12

mild - topical nystatin/clotrimazole troche 7-14 days

moderate-severe disease - fluconazole 200mg OD 7-14 days

refractory disease - itraconazole/voriconazole/posaconazole/amB

chronic recurrent - fluconazole 100mg 3x a week (note inc to fluconazole 200mg 3x a week if esophageal)

Question 13

How to manage chronic recurrent esophageal candidiasis?

Answer 13

fluconazole 200mg 3x a week

Question 14

How to manage native valve candida endocarditis?

How long to treat?

what if fluconazole resistant?

Answer 14

initially, iv echinocandin/amB

step down to fluconazole when candidaemia cleared, pt improve and sensitive

valve surgery

continue treatment for at least 6 weeks post valve surgery

If fluconazole resistant, PO voriconazole/posaconazole.

Question 15

Pt with native valve candida endocarditis. Can’t do valve surgery. How to manage?

what if fluconazole resistant?

Answer 15

initially, echinocandin/amB

step down to Po fluconazole when candidaemia cleared, pt well and sensitive

lifelong fluconazole 400mg OD

fluconazole resistant = Po voriconazole/posaconazole

Question 16

pt with prosthetic valve candida endocarditis. How to manage?

Answer 16

Same as native valve endocarditis

+ replace valve

+ chronic suppression with fluconazole 400mg daily

(if fluconazole-resistant, give posaconazole/voriconazole)

Question 17

patient with candida thrombophlebitis. how to manage?

Answer 17

As per candidaemia + catheter removal +I&D/resection of vein

resolution of thrombus can be considered as evidence to discontinue therapy if clinical and cultures allow.

Question 18

How to treat intra-abdominal candidiasis?

Answer 18

same as candidaemia

+ surgery to remove collections

Question 19

Implantable cardiac device - device candida infection. How to manage?

Answer 19

as per candida endocarditis - remove device, give AmB+-flucytosine/or echinocandin initially,

then step down to fluconazole when candidaemia cleared,

continue till at least 6 weeks post device removal.

if can’t remove device, then lifelong suppression with fluconazole 400mg daily.

Question 20

implantable cardiac device - pocket infection only. How to manage?

Answer 20

remove device, then 4 weeks antifungal treatment.

Question 21

implantable cardiac device - lead infection only. how to manage?

Answer 21

remove device, and 6 weeks antifungal treatment

Question 22

candida osteomyelitis. How to manage?

Answer 22

give fluconazole 400mg od 6-12 months,

or echinocandin at least 2 weeks then fluconazole 6-12months

Question 23

Native joint septic candida arthritis. How to manage?

Answer 23

surgical wash-out

fluconazole 400mg od for 6 weeks

OR

iv echinocandin first 2 weeks then fluconazole 4 weeks

Question 24

candida endophthalmitis without vitritis. No macular involvement. How to manage?

Answer 24

if susceptible, iv fluconazole/voriconazole for min 4-6wks, depending on lesion improvement.

if resistant, iv AmB

Question 25

Prosthetic joint septic candida arthritis. How to manage?

What if can’t remove prosthesis?

Answer 25

fluconazole 400mg od for 6 weeks/echinocandin 2weeks followed by fluconazole 4 weeks

+remove prosthesis

if can’t remove, then followed by chronic suppression fluconazole 400mg od lifelong.

Question 26

candida endophthalmitis without vitritis, but with macular involvement. How to manage?

Answer 26

if susceptible, iv fluconazole/voriconazole for min 4-6wks, depending on lesion improvement.

if resistant, iv AmB

PLUS

intravitreal injection with AmB/voriconazole

Question 27

Candida endophthalmitis with vitritis. How to manage?

Answer 27

1) if susceptible, iv fluconazole/voriconazole

if resistant, iv AmB

2) intravitreal injection with AmB/voriconazole
3) vitrectomy

min 4-6wks, depending on lesion improvement.

Question 28

How to treat CNS candidiasis?

Answer 28

1. Initially, AmB+- flucytosine
2. when got response, step down to fluconazole
3. remove CNS device. if can’t remove device, for intraventricular AmB

Duration if until CNS signs and symptoms resolve.