Candida infections diagnosis and management

Candida infections diagnosis and management

The range of diseases caused by Candida albicans is verybroad. It is a common commensal of the oral and vaginalmucosae at one extreme, and at the other it can causepneumonia, endocarditis, septicaemia and death.Candida can become a pathogen on damaged skin, inseverely ill patients, in patients who have specific immunedeficiency (especially AIDS), and in patients receivingbroad-spectrum antibiotics when the local microbialecology is disturbed. Both cell-mediated and humoralimmunity participate in control of Candida. Inheriteddeficiency of T-cell function causes severe but localizeddisease. In combined immune deficiency the infectionbecomes disseminated. Severely ill patients under intensivecare frequently have a mixed immune deficiency andare also receiving antibiotics that predispose to Candidainfection. Disseminated infections are also seen in intravenousdrug abusers.

Diagnosis of systemic Candida infectionCandida septicaemia is often a terminal event and overhalf of patients are diagnosed at postmortem. Clinical signsare usually minimal, but there may be endophthalmitis withfluffy yellow/white retinal spots resembling cottonwoolspots, or small abscesses may be detected elsewhere, suchas in the liver, where ultrasound-guided biopsy or aspirationcan clinch the diagnosis. Pulmonary infiltrates mayoccur on chest X-ray, with Candida in bronchial washings.Isolation of Candida from a single site on one occasiondoes not necessarily indicate serious infection, even whenit comes from a blood culture. The judgement that Candidais responsible for disease manifestations remains clinical.In view of the difficulty in diagnosis, treatment is given fordisseminated Candida infection if Candida is cultured frommore than one site in a severely ill patient in whom thereis new evidence of infection (e.g. fever) but bacterial infectionis judged to be unlikely.

Management Fluconazole is the first choice for disseminated candidiasis.It is given intravenously, 400 mg by infusion initially, followedby 200 mg daily until oral therapy can be substituted.Maintenance treatment is needed until antibiotics arestopped. Toxicity is very uncommon. If there is no responseto this drug amphotericin B is substituted, starting at0.25 mg/kg daily infused over 1 hour, increasing rapidly toabout 0.8 mg/kg daily. The maximum dose is limited by sideeffectssuch as fever, uraemia and bone marrow toxicity.

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