Also called candidosis and moniliasis, candidiasis is usually a mild, superficial fungal infection caused by the Candida genus. The infection usually affects the nails (onychomycosis), skin (diaper rash), or mucous membranes, especially the oropharynx (thrush), vagina (candidiasis), 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 and immunosuppressed patients. 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, and C. guilliermondii.
Although these fungi are part of the normal flora of the GI tract, mouth, vagina, and skin, they can cause infection when a change in the body permits their sudden proliferation —rising blood glucose levels from diabetes mellitus; lowered resistance from a disease (such as cancer), an immunosuppressant, radiation, aging, or human immunodeficiency virus (HIV) infection; or when they’re introduced systemically through I.V. or urinary catheter use, 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 infant of a mother with vaginal candidiasis can contract oral thrush while passing through the birth canal.
The incidence of candidiasis is rising because I.V. therapy is more widely used and because there are more immunocompromised patients, especially those with HIV infection.
Superficial candidiasis produces signs and symptoms that correspond to the following sites of infection:
❑ skin: scaly, erythematous, papular rash, sometimes covered with exudate, appearing below the breast, between the fingers, and at the axillae, groin, and umbilicus (With diaper rash, papules appear 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: cream-colored or bluish white patches of exudate on the tongue, mouth, or pharynx that reveal bloody engorgement when scraped. They may swell, causing respiratory distress in infants. Although they’re only occasionally painful, they cause a burning sensation in the throats and mouths of adults. (See Identifying thrush.)
❑ 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; and occasional rash. Specific signs and symptoms depend on the site of infection:
❑ pulmonary system: hemoptysis, fever, cough
❑ renal system: fever, flank pain, dysuria, hematuria, pyuria
❑ 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, exudate.
Identification of superficial candidiasis depends on evidence of Candida on a Gram stain of skin, vaginal scrapings, pus, or sputum or on skin scrapings. For systemic infections, a sample must be obtained for blood or tissue culture.
The first aim of treatment is to improve the underlying condition that predisposes the patient to candidiasis, such as controlling diabetes or discontinuing antibiotic therapy or catheterization, if possible.
Nystatin is an effective antifungal for superficial candidiasis. Clotrimazole, fluconazole, ketoconazole, and miconazole are effective for mucous membrane and vaginal Candida 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 with or without 5-fluorocytosine.
❑ If the patient is using nystatin solution, instruct him to swish it around in his mouth for several minutes before swallowing it.
❑ If the patient is an infant with thrush, swab nystatin on the oral mucosa.
❑ 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 prescribed topical anesthetic, such as lidocaine, at least 1 hour before meals. (It may suppress the gag reflex and cause aspiration.)
❑ If the patient has severe dysphagia, provide a soft diet. If he has mild dysphagia, tell him to chew his food thoroughly, and make sure he doesn’t choke.
❑ If the patient is obese, use cornstarch or dry padding in intertriginous areas to prevent irritation.
❑ Note insertion dates for I.V. catheters, and replace them according to facility 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. Administer acetaminophen, an antihistamine, or an antiemetic to help reduce adverse reactions.
❑ If the patient has a systemic infection, frequently check his vital signs. Provide appropriate supportive care.
❑ If the patient has renal involvement, carefully monitor intake and output and urine for blood and protein.
❑ Check high-risk patients daily, especially those receiving an antibiotic, for patchy areas, irritation, sore throat, bleeding of mouth or gums, or other signs and symptoms of superinfection. Check for vaginal discharge; record the color and amount.
❑ Encourage women in their third trimester of pregnancy to be examined for vaginal candidiasis to protect their child from infection at birth.
Read excerpts from these other book chapters related to Candida:
Copyright Details: Handbook of Diseases, Copyright © 2008 Williams & Wilkins.
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Title: Handbook of Diseases Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 1-58255-266-5 
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