Candidiasis (also called candidosis or moniliasis) is usually a mild, superficial fungal infection caused by the genus Candida. It usually infects the nails (onychomycosis), skin (diaper rash), or mucous membranes, especially the oropharynx (thrush), vagina (moniliasis), esophagus, and GI tract. Rarely, these fungi enter the bloodstream and invade the kidneys, lungs, endocardium, brain, or other structures, causing serious infections. Such systemic infection is most prevalent among drug abusers and patients already hospitalized, particularly diabetics, immunosuppressed patients, or patients receiving broad-spectrum antibiotics. The prognosis varies, depending on the patient's resistance.
Most cases of Candida infection result from C. albicans. Other infective strains include C. parapsilosis, C. tropicalis, C. glabrata, and C. guillermondii. These fungi are part of the normal flora of the GI tract, mouth, vagina, and skin. They cause infection when some change in the body (rising glucose levels from diabetes mellitus; lowered resistance from an immunosuppressive drug, radiation, aging, or a disease, such as cancer or human immunodeficiency virus [HIV] infection) permits their sudden proliferation or when they're introduced systemically by I.V. or urinary cath-eters, drug abuse, hyperalimentation, or surgery. However, the most common predisposing factor remains the use of broad-spectrum antibiotics, which decrease the number of normal flora and permit an increasing number of candidal organisms to proliferate. The of a mother with vaginal candidiasis can contract oral thrush while passing through the birth canal. Thrush is also found in many infants who are breast-fed. The incidence of candidiasis is rising because of wider use of I.V. therapy and a greater number of immunocompromised patients, especially those with HIV infection.
Symptoms of superficial candidiasis correspond to the site of infection:
❑skin — scaly, erythematous, papular rash, sometimes covered with exudate, appearing below the breast, between fingers, and at the axillae, groin, and umbilicus; in diaper rash, papules at the edges of the rash
❑nails — red, swollen, darkened nail bed; occasionally, purulent discharge and the separation of a pruritic nail from the nail bed
❑oropharyngeal mucosa (thrush) — cream-colored or bluish white curdlike patches of exudate on the tongue, mouth, or pharynx that reveal bloody engorgement when scraped. They may swell, causing respiratory distress in infants, or they may be painful or cause a burning sensation in the throats and mouths of adults. (See Recognizing candidiasis, page 214.)
❑esophageal mucosa — dysphagia, retrosternal pain, regurgitation and, occasionally, scales in the mouth and throat
❑vaginal mucosa — white or yellow discharge, with pruritus and local excoriation; white or gray raised patches on vaginal walls, with local inflammation; dyspareunia.
Systemic infection produces chills; high, spiking fever; hypotension; prostration; myalgias; arthralgias; and a rash. Specific signs and symptoms depend on the site of infection:
❑pulmonary — hemoptysis, cough, fever
❑renal — fever, flank pain, dysuria, hematuria, pyuria, cloudy urine
❑brain — headache, nuchal rigidity, seizures, focal neurologic deficits
❑endocardium — systolic or diastolic murmur, fever, chest pain, embolic phenomena
❑eye — endophthalmitis, blurred vision, orbital or periorbital pain, scotoma, and exudate.
Diagnosis of superficial candidiasis depends on clinical signs and symptoms plus evidence of Candida on a Gram stain of skin, vaginal scrapings, pus, or sputum or on skin scrapings prepared in potassium hydroxide solution. Systemic infections require obtaining a specimen for blood or tissue culture.
Treatment first aims to improve the underlying condition that predisposes the patient to candidiasis, such as controlling diabetes or discontinuing antibiotic therapy and catheterization, if possible.
Nystatin is an effective antifungal for superficial candidiasis. Clotrimazole, fluconazole, ketoconazole, and miconazole are effective in mucous-membrane and vaginal candidal infections. Ketoconazole or fluconazole is the treatment of choice for chronic candidiasis of the mucous membranes. Treatment for systemic infection consists of I.V. amphotericin B or fluconazole.
❑Instruct the patient using nystatin solution to swish it around in his mouth for several minutes before he swallows it.
❑Swab nystatin on the oral mucosa of an infant with thrush. Treat the infant after a feeding because feedings will wash the medication away. The infant's mother should also be treated to prevent the infection from being passed back and forth.
❑Provide the patient with a nonirritating mouthwash to loosen tenacious secretions and a soft toothbrush to avoid irritation.
❑Relieve the patient's mouth discomfort with a topical anesthetic, such as lidocaine, at least 1 hour before meals. (It may suppress the gag reflex and cause aspiration.)
❑Provide a soft diet for the patient with severe dysphagia. Tell the patient with mild dysphagia to chew food thoroughly, and make sure he doesn't choke.
❑Use dry padding in intertriginous areas of obese patients to prevent irritation.
❑Note dates of insertion of I.V. catheters, and replace them according to your hospital's policy to prevent phlebitis.
❑Assess the patient with candidiasis for underlying causes such as diabetes mellitus. If the patient is receiving amphotericin B for systemic candidiasis, he may have severe chills, fever, anorexia, nausea, and vomiting. Premedicate with acetaminophen, antihistamines, or antiemetics to help reduce adverse effects.
❑Frequently check vital signs of patients with systemic infections. Provide appropriate supportive care. In patients with renal involvement, carefully monitor intake and output and urine blood and protein levels.
❑Check high-risk patients daily, especially those receiving antibiotics, for patchy areas, irritation, sore throat, bleeding of the mouth or gums, or other signs of superinfection. Check for vaginal discharge; record color and amount.
❑Encourage women in their third tri-mester of pregnancy to be examined for vaginal candidiasis to protect their neonate from infection at birth.
Review other book chapters online related to Invasive candidiasis:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X 
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