What is candida

There are over 20 species of Candida yeasts that can cause infection in humans, the most common of which is Candida albicans ¹. The name ‘Candida’ refers to the white color of the organisms in culture. Candidal infection is known as ‘candidiasis’, ‘candidosis’ or ‘moniliasis’ (monilia is also a genus of ascomycete fungi). Candida depends on a living host for survival. Candida yeasts normally reside in the human intestinal tract from early infancy and can be found living on mucous membranes and skin without causing infection or disease; however, overgrowth of these organisms can cause symptoms to develop. Symptoms of candidiasis vary depending on the area of the body that is infected. If the host’s defences are lowered, the organism can cause infection of the mucosa (the lining of the mouth, anus and genitals), the skin, and rarely, deep-seated infection.

• Candida infections commonly occur in warm moist body areas, such as underarms. Usually your skin effectively blocks yeast, but any breakdown or cuts in the skin may allow this organism to penetrate.
• Typical affected areas in babies include the mouth and diaper areas.
• Vaginal yeast infection, which is the most common form of vaginitis is often referred to as vaginal Candidiasis.
• In adults, oral yeast infections become more common with increased age. Adults also can have yeast infections around dentures, in skin folds under the breast and lower abdomen, nailbeds, and beneath other skin folds. Most of these candida infections are superficial and clear up easily with treatment.
• Infections of the nailbeds often require prolonged therapy.
• Rarely, the yeast infection may spread throughout the body. In systemic candidal disease (in which the fungus enters the bloodstream and spreads throughout the body), up to 45% of people may die. Even common mouth and vaginal yeast infections can cause critical illness and can be more resistant to normal treatment.
• Yeast infections that return may be a sign of more serious diseases such as diabetes, leukemia, or AIDS.

Candida organisms are common commensals on mucosal surfaces in healthy individuals. No measures are available to reduce exposure to these fungi.

Candida albicans is a yeast-like fungus with budding and filamentous (pseudohyphal and hyphal) forms. Candida albicans can cause a wide range of clinical manifestations ranging from mild acute superficial infections to fatal disseminated disease. Disseminated candidiasis is almost exclusively seen in acquired or inherited immuno-deficiencies. Superficial candidiasis is the most common form.

In women, yeast infections are the second most common reason for vaginal burning, itching, and discharge. Yeast are found in the vagina of 20% to 50% of healthy women and can overgrow if the environment in the vagina changes. Antibiotic and steroid use is the most common reason for yeast overgrowth. However, pregnancy, menstruation, diabetes, and birth control pills also can contribute to getting a yeast infection. Yeast infections are more common after menopause.

In people who have a weakened immune system because of cancer treatments, steroids, or diseases such as AIDS, candida infections can occur throughout the entire body and can be life-threatening. The blood, brain, eye, kidney, and heart are most frequently affected, but Candida also can grow in the lungs, liver, and spleen. Candida is a leading cause of esophagitis (inflammation in the swallowing tube) in people with AIDS.

Almost 15% of people with weakened immune systems develop a systemic illness caused by Candida. These infections enter into the bloodstream through breakdowns or cuts in the skin or mucous membranes. Candidal organisms may build up in an area because of frequent use of antibiotics, which kill the bacteria that normally keep them under control.

Use of implanted devices and tubes that penetrate into the body like urinary catheters and IV ports/lines also provide access for the yeast to enter the body. IV drug users utilizing dirty needles may inject the yeast directly into their bloodstream or deep tissues.

Predisposing factors for candida infection:

• Infancy or old age
• Warm climate
• Occlusion e.g., plastic pants (babies), nylon pantyhose (women), dental plates
• Broad spectrum antibiotic treatment
• High-estrogen contraceptive pill or pregnancy
• Diabetes mellitus, Cushing syndrome and other endocrine conditions
• Iron deficiency
• General debility eg, from cancer or malnutrition
• Underlying skin disease e.g.,, psoriasis, lichen planus
• Immunodeficiency e.g., low levels of immunoglobulins, infection with human immunodeficiency virus (HIV)
• Chemotherapy or immunosuppressive medications including systemic steroids.

The most common Candida species to result in candidiasis is Candida albicans. Other species are:

• Candida tropicalis
• Candida parapsilosis
• Candida glabrata
• Candida guilliermondii

Candidiasis that develops in the mouth or throat is called “thrush” or oropharyngeal candidiasis. Candidiasis in the vagina is commonly referred to as a “yeast infection.” Candidiasis in the esophagus (the tube that connects the throat to the stomach) is called esophageal candidiasis or Candida esophagitis. Esophageal candidiasis is one of the most common infections in people living with HIV/AIDS ². Invasive candidiasis occurs when Candida species enter the bloodstream and spread throughout the body.

Candidal skin infections include:

• Oral candidiasis (oral thrush)
• Angular cheilitis
• Vulvovaginal candidiasis (genital infection in women) including cyclic vulvovaginitis
• Balanitis (penile infection)
• Intertrigo (skin fold infections)
• Napkin dermatitis (nappy or diaper rash)
• Chronic paronychia (nail fold infection)
• Onychomycosis (nail plate infection)
• Chronic mucocutaneous candidiasis

Invasive candidiasis

invasive candidiasis refers to spread of candida through the bloodstream (candidaemia) and infection of heart, brain, eyes, bones, and other tissues. This occurs in patients that are very unwell or that are immune suppressed. The common species of candida are usually found on culture, but sometimes one of about 15 other species are detected, such as:

• Candida auris
• Candida haemulonii

Candida auris is an emerging fungus that presents a serious global health threat. Healthcare facilities in several countries have reported that Candida auris has caused severe illness in hospitalized patients. Candida auris is often resistant to multiple antifungal drugs.

Candida auris

Candida auris is an emerging fungus that presents a serious global health threat. The Centers for Disease Control and Prevention (CDC) is concerned about Candida auris for three main reasons:

1. It is often multidrug-resistant, meaning that it is resistant to multiple antifungal drugs commonly used to treat Candida infections.
2. It is difficult to identify with standard laboratory methods, and it can be misidentified in labs without specific technology. Misidentification may lead to inappropriate management.
3. It has caused outbreaks in healthcare settings. For this reason, it is important to quickly identify C. auris in a hospitalized patient so that healthcare facilities can take special precautions to stop its spread.

CDC encourages all U.S. laboratory staff who identify Candida auris to notify their state or local public health authorities and CDC.

Candidiasis Infection Symptoms and Signs

Signs and symptoms of a candida infection can vary depending on the location of the infection.

• In women, signs and symptoms of a vaginal yeast infection are a white discharge that is thick and often described as having a cottage cheese appearance. The infection typically causes itching and irritates the vagina and surrounding outer tissues. On occasion there may be pain with sexual intercourse or burning with urination.
• Genital yeast infection in men: Men may develop symptoms of a genital yeast infection after intercourse with a woman who has a vaginal yeast infection. However, yeast infection is not considered to be a sexually-transmitted disease (STD) because women can have the yeast normally in the body and do not acquire it from an outside source. Most experts do not recommend treatment of male sex partners of women with candida yeast infection unless they develop symptoms. Symptoms can include itching and burning of the penis as well as a rash on the skin of the penis.
• In infants and adults, a candida infection can appear many different ways.
  • Oral candidiasis is called thrush. Thick, white lacy patches on top of a red base can form on the tongue, palate, or elsewhere inside the mouth. These patches sometimes look like milk curds but cannot be wiped away as easily as milk can. If the white plaques are wiped away with a blade or cotton-tipped applicator, the underlying tissue may bleed. This infection also may make the tongue look red without the white coating. Thrush can be painful and make it difficult to eat. Care should be given to make sure a person with thrush does not become dehydrated. Thrush was formerly referred to as moniliasis, based upon an older name for Candid albicans (Monilia).
  • Candida organisms naturally live on the skin, but breakdown of the outer layers of skin promote the yeast’s overgrowth. This typically occurs when the environment is warm and moist such as in diaper areas and skin folds. Superficial candida skin infections appear as a red flat rash with sharp scalloped edges. There are usually smaller patches of similar appearing rash nearby, known as “satellite lesions.” These rashes may cause itching or pain.
• In people with weakened immune systems, candidal infections can affect various internal organs and cause pain or dysfunction of the organ. People with suppressed immune systems due to AIDS, chemotherapy, steroids or other conditions may contract a yeast infection called esophagitis in their upper gastrointestinal (GI) systems. This infection is similar to thrush but extends down the mouth and esophagus to the stomach. Candida esophagitis can cause painful ulcers throughout the GI system, making it too painful to swallow even liquids. If the infection spreads into the intestines, food may be poorly absorbed. People with this condition are in danger of becoming dehydrated. There may be associated pain in the area of the sternum (breast bone), pain in the upper abdomen, and/or nausea and vomiting. If Candida gets into the bloodstream, the person may become sick with or without fever. If the infection spreads to the brain, they may have acute changes in mental function or behavior.

Types of Candidiasis

• Candida infections of the mouth, throat, and esophagus
• Vaginal Candidiasis
• Invasive Candidiasis

Candida infections of the mouth, throat, and esophagus

Candida normally lives in the digestive tract and on skin without causing any problems ³. Sometimes, Candida can multiply and cause an infection if the environment inside the mouth, throat, or esophagus changes in a way that encourages fungal growth.

The exact number of cases of candidiasis in the mouth, throat, and esophagus in the United States is difficult to determine because there is no national surveillance for these infections. The risk of these infections varies based on the presence of certain underlying medical conditions. For example, candidiasis in the mouth, throat, or esophagus is uncommon in healthy adults. However, they are some of the most common infections in people living with HIV/AIDS. In one study, approximately one-third of patients with advanced HIV infection had candidiasis in the mouth and throat ⁴.

Symptoms of candida infection of the mouth, throat, and esophagus

Candidiasis in the mouth and throat can have many different symptoms, including:

• White patches on the inner cheeks, tongue, roof of the mouth, and throat (photo showing candidiasis in the mouth)
• Redness or soreness
• Cottony feeling in the mouth
• Loss of taste
• Pain while eating or swallowing
• Cracking and redness at the corners of the mouth

Symptoms of candidiasis in the esophagus usually include pain when swallowing and difficulty swallowing. Contact your healthcare provider if you have symptoms that you think are related to candidiasis in the mouth, throat, or esophagus.

Figure 1. Oral candidiasis

Figure 2. Oral candidiasis

Figure 3. Skin candidiasis – superficial skin-fold infection caused by Candida also known as Candidal intertrigo

Note: Candidal intertrigo is triggered by a combination of the following factors:

• The hot and damp environment of skin folds, which is conducive to the growth of candida species, particularly Candida albicans ⁵
• Increased skin friction ⁶
• Immunocompromise ⁷.

Risk & Prevention of candida infection of the mouth, throat, and esophagus

Who gets candidiasis in the mouth, throat, or esophagus ?

Candidiasis in the mouth, throat, or esophagus is uncommon in healthy adults. People who are at higher risk for getting candidiasis in the mouth and throat include babies, especially those younger than one month old, and people who ⁸, ⁹, ¹⁰:

• Wear dentures
• Have diabetes
• Have cancer
• Have HIV/AIDS
• Take antibiotics or corticosteroids, including inhaled corticosteroids for conditions like asthma
• Take medications that cause dry mouth or have medical conditions that cause dry mouth
• Smoke

Most people who get candidiasis in the esophagus have weakened immune systems, meaning that their bodies don’t fight infections well. This includes people living with HIV/AIDS and people who have blood cancers such as leukemia and lymphoma. People who get candidiasis in the esophagus often also have candidiasis in the mouth and throat.

How can you prevent candida infection in the mouth, throat, or esophagus ?

Ways to help prevent candidiasis in the mouth and throat include:

• Maintain good oral health
• Rinse your mouth or brush your teeth after using inhaled corticosteroids
• Some studies have shown that chlorhexidine mouthwash may help to prevent oral candidiasis in people undergoing cancer treatment

Diagnosis & Testing of candida infection of the mouth, throat, and esophagus

Healthcare providers can usually diagnose candidiasis in the mouth or throat simply by looking inside.8 Sometimes a healthcare provider will take a small sample from the mouth or throat. The sample is sent to a laboratory for testing, usually to be examined under a microscope.

Healthcare providers usually diagnose candidiasis in the esophagus by doing an endoscopy. An endoscopy is a procedure to examine the digestive tract using a tube with a light and a camera. A healthcare provider might prescribe antifungal medication without doing an endoscopy to see if the patient’s symptoms get better.

Treatment of candida infection of the mouth, throat, and esophagus

Candidiasis in the mouth, throat, or esophagus is usually treated with antifungal medicine. The treatment for mild to moderate infections in the mouth or throat is usually an antifungal medicine applied to the inside of the mouth for 7 to 14 days. These medications include clotrimazole, miconazole, or nystatin. For severe infections, the treatment is usually fluconazole or another type of antifungal medicine given by mouth or through a vein for people who don’t get better after taking fluconazole. The treatment for candidiasis in the esophagus is usually fluconazole. Other types of prescription antifungal medicines can also be used for people who can’t take fluconazole or who don’t get better after taking fluconazole.

Table 1. Treating Mucosal Candidiasis

Treating Mucosal Candidiasis Oropharyngeal Candidiasis: Initial Episodes (Duration of Therapy: 7–14 days) Preferred Therapy: Fluconazole 100 mg PO once daily or Alternative Therapy: Clotrimazole troches 10 mg PO 5 times daily or Miconazole mucoadhesive buccal tablet 50 mg: Apply to mucosal surface over the canine fossa once daily (do not swallow, chew, or crush tablet). Refer to product label for more detailed application instructions or Itraconazole oral solution 200 mg PO daily or Posaconazole oral suspension 400 mg PO BID for one day, then 400 mg daily or Nystatin suspension 4–6 mL QID or 1–2 flavored pastilles 4–5 times daily Esophageal candidiasis (Duration of Therapy: 14–21 days) Note: Systemic antifungals are required for effective treatment of esophageal candidiasis Preferred Therapy: Fluconazole 100 mg (up to 400 mg) PO or IV daily or Itraconazole oral solution 200 mg PO daily Alternative Therapy: Voriconazole 200 mg PO or IV BID or Isavuconazole 200 mg PO as a loading dose, followed by 50 mg PO daily or Isavuconazole 400 mg PO as a loading dose, followed by 100 mg PO daily or Isavuconazole 400 mg PO once-weekly or Caspofungin 50 mg IV daily or Micafungin 150 mg IV daily or Anidulafungin 100 mg IV for one dose, then 50 mg IV daily or Amphotericin B deoxycholate 0.6 mg/kg IV daily or Lipid formulation of amphotericin B 3-4 mg/kg IV daily Note: A higher rate of esophageal candidiasis relapse has been reported with echinocandins than with fluconazole. Uncomplicated Vulvovaginal Candidiasis Preferred Therapy: Oral fluconazole 150 mg for 1 dose or Topical azoles (i.e., clotrimazole, butoconazole, miconazole, tioconazole, or terconazole) for 3–7 days Alternative Therapy: Itraconazole oral solution 200 mg PO daily for 3-7 days Note: Severe or recurrent vaginitis should be treated with oral fluconazole (100–200 mg) or topical antifungals for ≥7 days

Chronic Suppressive Therapy Chronic suppressive therapy is usually not recommended unless patients have frequent or severe recurrences. If used, it is reasonable to discontinue therapy if CD4 count >200 cells/mm3 If Decision Is To Use Suppressive Therapy Oropharyngeal Candidiasis: Fluconazole 100 mg PO once daily or 3 times weekly Esophageal Candidiasis: Fluconazole 100–200 mg PO daily Posaconazole oral suspension 400 mg PO BID Vulvovaginal Candidiasis: Fluconazole 150 mg PO once weekly

Other Considerations Chronic or prolonged use of azoles might promote development of resistance.

[Source ¹¹]

Vaginal Candidiasis

Candida normally lives inside the body (in places such as the mouth, throat, gut, and vagina) and on skin without causing any problems.

Scientists estimate that about 20% of women normally have Candida in the vagina without having any symptoms ¹². Sometimes, Candida can multiply and cause an infection if the environment inside the vagina changes in a way that encourages its growth. This can happen because of hormones, medicines, or changes in the immune system. Vaginal yeast infections are extremely common. Seventy-five percent of all women develop a yeast infection at some point during their lives. Vaginal candidiasis can be more frequent in people with weakened immune systems. When Candida albicans in the vagina multiplies to the point of infection, this infection can cause vaginal inflammation, irritation, odor, discharge, and itching.

Candidiasis in the vagina is commonly called a “vaginal yeast infection.” Other names for this infection are “vaginal candidiasis,” “vulvovaginal candidiasis,” or “candidal vaginitis.” The fungus most commonly associated with vaginal yeast infection is called Candida albicans, which account for up to 92% of all cases, with the remainder due to other species of Candida.

Vaginal candidiasis is common. In the United States, it is the second most common type of vaginal infection after bacterial vaginal infections ¹². More research is needed to determine the number of women who are affected and how many have vaginal candidiasis that keeps coming back after getting better (more than three times per year). The number of cases of vaginal candidiasis in the United States is difficult to determine because there is no national surveillance for this infection.

A vaginal yeast infection is not considered a sexually-transmitted infection (STI), but 12% to 15% of men develop symptoms such as itching and penile rash following sexual contact with an infected partner.

Under normal circumstances, a vaginal yeast infection is not serious and can be treated with medications. However, a vaginal yeast infection can be a sign an underlying, more serious condition or can lead to serious complications, especially if left untreated.

Vaginal candida infections, under normal circumstances, are usually treatable with over-the-counter medications. However, many women mistake other conditions for vaginal yeast infections, and these other conditions cannot be treated with the same medications that are used for yeast infection. Women, especially those with immune systems problems, should always consult their doctor upon experiencing symptoms of a yeast infection.

Symptoms of vaginal candidiasis

The symptoms of vaginal candidiasis include ¹³, ¹²:

• Vaginal itching or soreness
• Irritated vagina and vaginal area
• Pain during sexual intercourse
• Pain or discomfort when urinating
• Abnormal vaginal discharge (typically white-gray and thick, with a consistency resembling cottage cheese)

Although most vaginal candidiasis is mild, some women can develop severe infections involving redness, swelling, and cracks in the wall of the vagina.

Contact your healthcare provider if you have any of these symptoms. These symptoms are similar to those of other types of vaginal infections, which are treated with different types of medicines. A healthcare provider can tell you if you have vaginal candidiasis and how to treat it.

Risk & Prevention of vaginal candidiasis

Who gets vaginal candidiasis ?

Vaginal candidiasis is common, though more research is needed to understand how many women are affected. Women who are more likely to get vaginal candidiasis include those who:

• Are pregnant
• Use hormonal contraceptives (for example, birth control pills)
• Have diabetes. This disease can lower the glycogen store in certain vaginal cells. Diabetes may also raise the sugar content (and pH) of the vagina, which increases the risk for developing a vaginal yeast infection.
• Have a weakened immune system (for example, due to HIV infection or medicines that weaken the immune system, such as steroids and chemotherapy)
• Are taking or have recently taken antibiotics. Antibiotics can destroy bacteria that protect the vagina or alter the balance of bacteria that are normally present. A vaginal yeast infection may develop during or after the use of antibiotics taken to treat other conditions such as strep throat.
• Steroid use
• Use of douches or feminine hygiene sprays
• Scratches or wounds in the vagina (for example, caused during insertion of tampons or other objects).
• Underwear that is tight or made of a material other than cotton. (This can increase temperature, moisture, and local irritation.)
• Hormonal changes:
  • ovulation
  • menopause
  • pregnancy
  • birth control pills
  • hormone therapy

How can you prevent vaginal candida infection ?

Wearing cotton underwear might help reduce the chances of getting a yeast infection. Because taking antibiotics can lead to vaginal candidiasis, take these medicines only when prescribed and exactly as your healthcare provider tells you.

The following are guidelines women should follow to help prevent the likelihood of developing a vaginal yeast infection:

• Keep the vaginal area dry, especially after a shower
• Wipe from front to rear after using the toilet
• Wear looser-fitting cotton underwear, which help to keep the vaginal area dry and may reduce irritation
• After swimming, change out of a wet bathing suit
• Avoid chemical irritants in deodorant tampons
• Do not use douches or feminine hygiene products, regular bathing is usually adequate to cleanse the vagina

Diagnosis & Testing of vaginal candidiasis

A laboratory test is usually needed to diagnose vaginal candidiasis because the symptoms are similar to those of other types of vaginal infections. A healthcare provider will usually diagnose vaginal candidiasis by taking a small sample of vaginal discharge to be examined under a microscope or sent to a laboratory for a fungal culture. However, a positive fungal culture does not always mean that Candida is causing the symptoms because some women can have Candida in the vagina without having any symptoms.

Treatment of vaginal candidiasis

Vaginal candidiasis is usually treated with antifungal medicine ⁸. For most infections, the treatment is an antifungal medicine applied inside the vagina or a single dose of fluconazole taken by mouth. For more severe infections, infections that don’t get better, or keep coming back after getting better, other treatments might be needed. These treatments include more doses of fluconazole taken by mouth or other medicines applied inside the vagina such as boric acid, nystatin, or flucytosine.

Fluconazole (Diflucan) is the most commonly used oral medication for yeast infection. It may produce side effects such as nausea, headache, and abdominal pain. It is usually given in one dose of 150 mg.

Medications are also available in the form of vaginal tablets or cream applicators. These medications include the following:

• miconazole (M-Zole Dual Pack, Micon 7, Monistat 3, Monistat 5, Monistat 7)
• tioconazole (Monistat-1, Vagistat-1)
• butoconazole (Gynazole 1)
• clotrimazole (Mycelex-G, Femcare, Gyne-Lotrimin) (Reported cure rate of about 85% to 90%)
• nystatin (Mycostatin) (Reported cure rate of about 75% to 80%)
• terconazole (Terazol 3, Terazol 7)

In some cases, a single dose of medication has been shown to clear up yeast infections. In other cases, a longer period of medication (three days or seven days) might be prescribed.

In women who have weakened immune systems, more than one dose of oral medications may be prescribed. In these women, a longer course of topical medications (seven to 14 days) is also recommended.

For recurrent infection (more than four episodes per year), oral fluconazole and itraconazole or vaginal clotrimazole might be needed for six months. Oral medications are typically recommended if the symptoms are severe. In pregnant women, a longer course of treatment may be needed. Women should consult with their doctor before treatment. Women with an allergy to any ingredients contained within these products should not take them.

Vaginal Yeast Infection Home Remedies

For confirmed vaginal yeast infections, over-the-counter medications are available that are usually effective in treating them. The cure rates associated with the nonprescription drugs are about 75% to 90%. However, women who do not have a vaginal yeast infection account for two thirds of all yeast-infection remedies purchased in stores. By using these medications, these women may increase their likelihood of developing a yeast infection that is resistant to future treatment.

Medications to treat vaginal yeast infections come in a variety of forms, including oral medications, vaginal suppositories, and creams. Suppositories are inserted into the vagina. Cream medications are massaged into the vagina and surrounding tissues. Most Candidal infections that are treated at home with over-the-counter or prescription medications clear within a week. People with a weakened immune system should consult their doctor before attempting home-care medications or remedies, as prolonged treatment times may be recommended.

Women who experience increased irritation should immediately discontinue the medication. Pregnant women should consult their doctor before using any of these medications. Women whose symptoms last more than one week after treatment should consult their doctor to treat a severe infection or rule out other types of infections or underlying causes.

The following are common home-care techniques, although scientific studies have NOT proven their effectiveness:

• Vinegar douches: Many women douche following menstrual periods or intercourse. However, doctors discourage such routine cleaning. The vagina is naturally designed to clean itself, and douching may remove healthy bacteria that line the vagina. Attempting to treat an abnormal vaginal discharge by douching may worsen the condition.
• Eating yogurt that contains live acidophilus cultures (or eating acidophilus capsules): Yogurt acts as a medium for certain good bacteria to thrive. Despite popular belief, studies about the benefits of eating yogurt with lactobacillus acidophilus cultures as a way to prevent yeast infection have yielded conflicting results. The scientific benefit of consuming yogurt cultures has not yet been proven.
• Antihistamines or topical anesthetics: These are numbing medications that may mask the symptoms of a vaginal yeast infection. However, they do not treat the underlying cause.

Invasive Candidiasis

Invasive candidiasis is an infection caused by a yeast (a type of fungus) called Candida. Unlike Candida infections in the mouth and throat (also called “thrush”) or vaginal “yeast infections,” invasive candidiasis is a serious infection that can affect the blood, heart, brain, eyes, bones, and other parts of the body ¹⁴.

Candidemia, a bloodstream infection with Candida, is a common infection in hospitalized patients.

Candida normally lives in the gastrointestinal tract and on skin without causing any problems ¹⁵. However, in certain patients who are at risk, Candida can enter the bloodstream and cause an infection. In the United States, candidemia is one of the most common causes of bloodstream infections in hospitalized patients ¹⁶, ¹⁷ and it often results in long hospital stays, high medical costs, and poor outcomes ¹⁸.

Invasive candidiasis can be treated with antifungal medication, and antifungal medication is often given to prevent the infection from developing in certain patient groups ¹⁹.

Who gets invasive candidiasis ?

Most cases of invasive candidiasis occur in people who have recently been admitted to a hospital or been in contact with other healthcare settings such as nursing homes. People who are at high risk for developing invasive candidiasis include ²⁰:

• Patients who have a central venous catheter
• Patients in the intensive care unit (ICU)
• People who have weakened immune systems (for example, people who have had an organ transplant, have human immunodeficiency virus (HIV) infection/AIDS, or are on cancer chemotherapy)
• People who have taken broad-spectrum antibiotics
• People who have a very low neutrophil (a type of white blood cell) count (neutropenia)
• People who have kidney failure or are on hemodialysis
• Patients who have had surgery, especially gastrointestinal surgery
• Patients who have diabetes
• Systemic malignancy (cancer)
• Organ transplant recipients
• Poorly controlled diabetes mellitus
• Very old or very young.

Is invasive candidiasis contagious ?

Invasive candidiasis doesn’t spread directly from person to person. However, some species of the fungus that causes invasive candidiasis normally live on skin, so it’s possible that Candida can be passed from one person to another and possibly cause an infection in someone who is at high risk ²¹.

Invasive candidiasis clinical features

The clinical features of the invasive candidiasis illness depend on the specific infection and which organs have been affected. Infections in people with normal immune function may result in very minor symptoms or none at all (this is called subclinical infection). General symptoms of illness may include:

• Fever
• Cough
• Loss of appetite

Lungs

Invasive lung candidiasis typically result in a progressive dry cough, shortness of breath, pain when taking a deep breath and fever. These symptoms may progress to the point of life threatening acute respiratory distress syndrome. Hemoptysis (the coughing up of blood) is also sometimes seen, particularly if inflammation of the large airways is present.

Bone

Bone infection can develop from spread through the blood or rarely via direct spread from an overlying ulcer and infected skin. Fever and pain in the affected bone are the cardinal symptoms. This would usually be investigated with x-rays, CT scanning and an aspiration (suction for sampling) via a needle to obtain a specimen for culture.

Brain

Brain involvement by systemic candidiasis has a particularly high mortality associated with it. Symptoms suggesting involvement of the brain include headaches, seizures and deficits in normal brain control over movement or sensation. These are assessed by CT or MRI brain scans and if suggestive, then may be followed up by biopsy of the brain.

Meningitis (inflammation of the tissue surrounding the brain) can develop, particularly with Candidiasis. Symptoms usually include headache, stiff neck and irritability.

Eyes

Almost any of the eye structures may be infected by Candida. The symptoms depend on which part of the eye is infected but may include visual blurring, dark or black images floating in the visual field, pain and a red eye.

Skin

A variety of skin changes may be seen in association with systemic mycoses. The skin lesions depend partly on which fungus is the cause.

• Single or widespread lesions
• Small red papules or larger nodules
• Purpuric lesions may resemble ecthyma gangrenosum or purpura fulminans

How can invasive candidiasis be prevented ?

Antifungal medication. If you’re at high risk for developing invasive candidiasis, your healthcare provider may prescribe antifungal medication to prevent the infection. This is called “antifungal prophylaxis,” and it is typically recommended for ¹⁹:

• Some organ transplant patients
• High-risk ICU patients
• Chemotherapy patients who have neutropenia
• Stem cell transplant patients who have neutropenia

Some doctors may also consider giving antifungal prophylaxis to very low birth weight infants (less than 2.2 pounds) in nurseries with high rates of invasive candidiasis.

Be a safe patient. There are some actions that you can take to help protect yourself from infections, including:

Speak up. Patients and caregivers can ask how long a central venous catheter (central line) is needed, and if so, how long it should stay in place. Tell your doctor if the skin around the catheter becomes red or painful.

Keep hands clean. Be sure everyone cleans their hands before touching you. Washing hands can prevent the spread of germs.

For more tips, please see CDC’s webpage about What You Can Do to Be a Safe Patient ²².

How is invasive candidiasis diagnosed ?

Healthcare providers rely on your medical history, symptoms, physical examinations, and laboratory tests to diagnose invasive candidiasis. The most common way that healthcare providers test for invasive candidiasis is by taking a blood sample and sending it to a laboratory to see if it will grow Candida in a culture.

How is invasive candidiasis treated ?

The specific type and dose of antifungal medication used to treat invasive candidiasis usually depends on the patient’s age, immune status, and location and severity of the infection. For most adults, the initial recommended antifungal treatment is an echinocandin (caspofungin, micafungin, or anidulafungin) given through the vein (intravenous or IV). Fluconazole, amphotericin B, and other antifungal medications may also be appropriate in certain situations.

How long does the treatment last ?

For candidemia, treatment should continue for 2 weeks after signs and symptoms have resolved and Candida yeasts are no longer in the bloodstream. Other forms of invasive candidiasis, such as infections in the bones, joints, heart, or central nervous system, usually need to be treated for a longer period of time.

Gastrointestinal Candida colonization

Candida albicans is almost always found associated with humans or other mammals, typically in the gastrointestinal (GI) tract, genitourinary tract or on skin ²³. Colonizing organisms are thought to be benign, but in an immunocompromised host, colonizing organisms give rise to invasive organisms that are capable of causing life-threatening infections. Since C. albicans lacks any apparent environmental reservoir, Candida albicans cells generally grow in association with a mammalian host. Candida albicans is a very effective colonizer of humans. For example, Russell and Lay found that 47% of 1-month-old infants were orally colonized with Candida albicans and 49% were colonized with other fungi ²⁴. To achieve such efficient colonization, Candida albicans cells must possess adaptations that optimize their ability to colonize. The activities that promote commensal colonization in a healthy host could uniquely function only during colonization, or they may be identical to the activities that promote virulence in an immunocompromised host.

In the GI tract, Candida albicans encounters and responds to varying features of the physical environment such as pH, oxygen levels and nutrient levels ²⁵. Candida albicans also responds to secretions produced in the GI tract such as bile ²⁶. These findings argue that Candida albicans is well adapted for growth in the GI tract.

Analyses of factors that regulate Candida albicans colonization show that the host immune system ²⁷, bacterial competitors ²⁸, and fungal gene expression ²⁹ impact GI tract colonization by the organism. Colonization levels thus reflect an interplay between host activities, bacterial activities and fungal activities.

Candida colonization is associated with diseases of the GI tract

Candida colonization in patients suffering from GI tract disease has been documented in several situations. As shown in Table 2, patients with different diseases affecting the GI tract were colonized with Candida more frequently than control individuals.

Table 2. Fungal colonization in patients with GI tract disease

What is a candida cleanse diet

Some complementary and alternative medicine practitioners blame common symptoms such as fatigue, headache and poor memory on overgrowth of the fungus-like organism Candida albicans in the intestines, sometimes called “yeast syndrome.”

To cure the syndrome, they recommend a candida cleanse diet. The diet eliminates sugar, white flour, yeast and cheese, based on the theory that these foods promote candida overgrowth.

It’s considered normal to find candida in the human gut (gastrointestinal tract), but an overgrowth of candida can exacerbate existing gastrointestinal diseases such as ulcerative colitis and Crohn’s disease.

However, there is little evidence that dietary changes can improve the effects of a yeast overgrowth if you have these conditions. Doctors usually prescribe antifungal medications to treat yeast overgrowth, which is diagnosed by putting a small scope into your stomach (endoscopy) and taking a tiny sample of your stomach lining (biopsy).

Unfortunately, there isn’t much evidence to support the diagnosis of yeast syndrome. And there are no clinical trials that document the efficacy of a candida cleanse diet for treating any recognized medical condition.

Not surprisingly, many people note improvement in various symptoms when following this diet. If you stop eating sugar and white flour, you’ll generally wind up cutting out most processed foods, which tend to be higher in calories and lower in nutritive value.

Within a few weeks of replacing processed foods with fresh ones and white flour with whole grains, you may start to feel better in general. That, rather than stopping the growth of yeast in the gastrointestinal tract, is probably the main benefit of a candida cleanse diet.

References

1. Candidiasis. Centers for Disease Control and Prevention. https://www.cdc.gov/fungal/diseases/candidiasis/index.html
2. Buchacz K, Lau B, Jing Y, et al. Incidence of AIDS-Defining Opportunistic Infections in a Multicohort Analysis of HIV-infected Persons in the United States and Canada, 2000-2010. The Journal of infectious diseases 2016;214:862-72.
3. Nucci M, Anaissie E. Revisiting the source of candidemia: skin or gut? Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2001;33:1959-67.
4. Thompson GR, 3rd, Patel PK, Kirkpatrick WR, et al. Oropharyngeal candidiasis in the era of antiretroviral therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:488-95.
5. Yaar M, Gilchrest BA. Aging of skin. In: Fitzpatrick’s Dermatology in General Medicine, Freedberg IM, Eisen AZ, Wolff K, et al (Eds), McGraw-Hill, New York 2003. p.1386
6. Garcia Hidalgo L. Dermatologic complications of obesity. Am J Clin Dermatol. 2002;3(7):497. https://www.ncbi.nlm.nih.gov/pubmed/12180897
7. Jautova J, Baloghova J, Dorko E, et al. Cutaneous candiosis in immunosuppressed patients. Folia Microbiol. 2001;46(4):359. https://link.springer.com/article/10.1007%2FBF02815627
8. Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2016;62:e1-50.
9. Lalla RV, Latortue MC, Hong CH, et al. A systematic review of oral fungal infections in patients receiving cancer therapy. Support Care Cancer 2010;18:985-92.
10. Pankhurst CL. Candidiasis (oropharyngeal). BMJ Clin Evid 2013;2013:1304.
11. Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. https://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-opportunistic-infection/331/candida
12. Sobel JD. Vulvovaginal candidosis. Lancet 2007;369:1961-71.
13. Goncalves B, Ferreira C, Alves CT, Henriques M, Azeredo J, Silva S. Vulvovaginal candidiasis: Epidemiology, microbiology and risk factors. Critical reviews in microbiology 2016;42:905-27.
14. Definition of Invasive Candidiasis. Centers for Disease Control and Prevention. https://www.cdc.gov/fungal/diseases/candidiasis/invasive/definition.html
15. Nucci M, Anaissie E. Revisiting the source of candidemia: skin or gut? Clin Infect Dis. 2001 Dec 15;33(12):1959-67.
16. Wisplinghoff H, Bischoff T, Tallent SM, Seifert H, Wenzel RP, Edmond MB. Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis. 2004 Aug 1;39(3):309-17.
17. Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, et al. Multistate point-prevalence survey of health care-associated infections. The New England journal of medicine. 2014 Mar 27;370(13):1198-208.
18. Morgan J, Meltzer MI, Plikaytis BD, Sofair AN, Huie-White S, Wilcox S, et al. Excess mortality, hospital stay, and cost due to candidemia: a case-control study using data from population-based candidemia surveillance. Infect Control Hosp Epidemiol 2005 Jun;26(6):540-7.
19. Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Feb 15;62(4):e1-e50.
20. Pfaller MA, Diekema DJ. Epidemiology of invasive candidiasis: a persistent public health problem. Clin Microbiol Rev. 2007 Jan;20(1):133-63.
21. Strausbaugh LJ, Sewell DL, Ward TT, Pfaller MA, Heitzman T, Tjoelker R. High frequency of yeast carriage on hands of hospital personnel. J Clin Microbiol. 1994 Sep;32(9):2299-300.
22. Patient Safety: What You Can Do to Be a Safe Patient. https://www.cdc.gov/HAI/patientSafety/patient-safety.html
23. Candida infections: an overview. Odds FC. Crit Rev Microbiol. 1987; 15(1):1-5. https://www.ncbi.nlm.nih.gov/pubmed/3319417
24. Natural history of Candida species and yeasts in the oral cavities of infants. Russell C, Lay KM. Arch Oral Biol. 1973 Aug; 18(8):957-62. https://www.ncbi.nlm.nih.gov/pubmed/4581575/
25. Adaptations of Candida albicans for growth in the mammalian intestinal tract. Rosenbach A, Dignard D, Pierce JV, Whiteway M, Kumamoto CA. Eukaryot Cell. 2010 Jul; 9(7):1075-86. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2901676/
26. Sodium choleate (NaCho) effects on Candida albicans: implications for its role as a gastrointestinal tract inhabitant. Vu B, Essmann M, Larsen B. Mycopathologia. 2010 Mar; 169(3):183-91. https://www.ncbi.nlm.nih.gov/pubmed/19876762/
27. IL-23 and the Th17 pathway promote inflammation and impair antifungal immune resistance. Zelante T, De Luca A, Bonifazi P, Montagnoli C, Bozza S, Moretti S, Belladonna ML, Vacca C, Conte C, Mosci P, Bistoni F, Puccetti P, Kastelein RA, Kopf M, Romani L. Eur J Immunol. 2007 Oct; 37(10):2695-706. https://www.ncbi.nlm.nih.gov/pubmed/17899546/
28. Effects of broad-spectrum antimicrobial agents on yeast colonization of the gastrointestinal tracts of mice. Samonis G, Anaissie EJ, Bodey GP. Antimicrob Agents Chemother. 1990 Dec; 34(12):2420-2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC172073/pdf/aac00068-0154.pdf
29. Hypoxia and extraintestinal dissemination of Candida albicans yeast forms. Kim AS, Garni RM, Henry-Stanley MJ, Bendel CM, Erlandsen SL, Wells CL. Shock. 2003 Mar; 19(3):257-62. https://www.ncbi.nlm.nih.gov/pubmed/12630526
30. Standaert-Vitse A, Sendid B, Joossens M, Francois N, Vandewalle-El Khoury P, Branche J, Van Kruiningen H, Jouault T, Rutgeerts P, Gower-Rousseau C, et al. Candida albicans colonization and ASCA in familial Crohn’s disease. Am J Gastroenterol. 2009;104:1745–1753. High level colonization with Candida albicans is associated with familial Crohn’s disease. https://www.ncbi.nlm.nih.gov/pubmed/19471251
31. Zwolinska-Wcislo M, Brzozowski T, Budak A, Kwiecien S, Sliwowski Z, Drozdowicz D, Trojanowska D, Rudnicka-Sosin L, Mach T, Konturek SJ, et al. Effect of Candida colonization on human ulcerative colitis and the healing of inflammatory changes of the colon in the experimental model of colitis ulcerosa. J Physiol Pharmacol. 2009;60:107–118. https://www.ncbi.nlm.nih.gov/pubmed/19439813
32. Ksiadzyna D, Semianow-Wejchert J, Nawrot U, Wlodarczyk K, Paradowski L. Serum concentration of interleukin 10, anti-mannan Candida antibodies and the fungal colonization of the gastrointestinal tract in patients with ulcerative colitis. Adv Med Sci. 2009;54:170–176. https://www.ncbi.nlm.nih.gov/pubmed/19758974
33. Zwolinska-Wcislo M, Brzozowski T, Mach T, Budak A, Trojanowska D, Konturek PC, Pajdo R, Drozdowicz D, Kwiecien S. Are probiotics effective in the treatment of fungal colonization of the gastrointestinal tract? Experimental and clinical studies. J Physiol Pharmacol. 2006;57 (Suppl 9):35–49. https://www.ncbi.nlm.nih.gov/pubmed/17242486
34. Goenka MK, Kochhar R, Chakrabarti A, Kumar A, Gupta O, Talwar P, Mehta SK. Candida overgrowth after treatment of duodenal ulcer. A comparison of cimetidine, famotidine, and omeprazole. J Clin Gastroenterol. 1996;23:7–10. https://www.ncbi.nlm.nih.gov/pubmed/8835890
35. Nakamura T, Yoshida M, Otani Y, Kameyama K, Ishikawa H, Kumai K, Kubota T, Saikawa Y, Kitajima M. Twelve years’ progress in surgery for perforated gastric and duodenal ulcers: a retrospective study of indications for laparoscopic surgery, post-operative course and the influence of Candida infection. Aliment Pharmacol Ther. 2006;24 (Suppl 4):297–302.
36. Lee SC, Fung CP, Chen HY, Li CT, Jwo SC, Hung YB, See LC, Liao HC, Loke SS, Wang FL, et al. Candida peritonitis due to peptic ulcer perforation: incidence rate, risk factors, prognosis and susceptibility to fluconazole and amphotericin B. Diagn Microbiol Infect Dis. 2002;44:23–27. https://www.ncbi.nlm.nih.gov/pubmed/12376027