Antibiotic candidiasis
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Candidiasis is a
fungal infection Fungal infection, also known as mycosis, is disease caused by fungi. Different types are traditionally divided according to the part of the body affected; superficial, subcutaneous, and systemic. Superficial fungal infections include common ti ...
due to any type of '' Candida'' (a type of yeast). When it affects the mouth, in some countries it is commonly called thrush. Signs and symptoms include white patches on the tongue or other areas of the mouth and throat. Other symptoms may include soreness and problems swallowing. When it affects the vagina, it may be referred to as a yeast infection or thrush. Signs and symptoms include genital itching, burning, and sometimes a white "cottage cheese-like" discharge from the vagina. Yeast infections of the penis are less common and typically present with an itchy rash. Very rarely, yeast infections may become invasive, spreading to other parts of the body. This may result in fevers along with other symptoms depending on the parts involved. More than 20 types of ''Candida'' can cause infection with '' Candida albicans'' being the most common. Infections of the mouth are most common among children less than one month old, the elderly, and those with weak immune systems. Conditions that result in a weak immune system include HIV/AIDS, the medications used after organ transplantation, diabetes, and the use of
corticosteroid Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are involv ...
s. Other risks include dentures, following
antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention of ...
therapy, and breastfeeding. Vaginal infections occur more commonly during pregnancy, in those with weak immune systems, and following antibiotic use. Individuals at risk for
invasive candidiasis Invasive candidiasis is an infection (candidiasis) that can be caused by various species of ''Candida'' yeast. Unlike ''Candida'' infections of the mouth and throat (oral candidiasis) or vagina ( ''Candidal'' vulvovaginitis), invasive candidias ...
include low birth weight babies, people recovering from surgery, people admitted to intensive care units, and those with an otherwise compromised immune system. Efforts to prevent infections of the mouth include the use of chlorhexidine mouthwash in those with poor immune function and washing out the mouth following the use of inhaled steroids. Little evidence supports probiotics for either prevention or treatment, even among those with frequent vaginal infections. For infections of the mouth, treatment with topical
clotrimazole Clotrimazole, sold under the brand name Lotrimin, among others, is an antifungal medication. It is used to treat vaginal yeast infections, oral thrush, diaper rash, tinea versicolor, and types of ringworm including athlete's foot and jock itch ...
or nystatin is usually effective. Oral or intravenous fluconazole, itraconazole, or amphotericin B may be used if these do not work. A number of topical antifungal medications may be used for vaginal infections, including clotrimazole. In those with widespread disease, an
echinocandin Echinocandins are a class of antifungal drugs that inhibit the synthesis of β-glucan in the fungal cell wall via noncompetitive inhibition of the enzyme 1,3-β glucan synthase. The class has been termed the " penicillin of antifungals," along ...
such as
caspofungin Caspofungin (INN) (brand name Cancidas) is a lipopeptide antifungal drug from Merck & Co., Inc. discovered by James Balkovec, Regina Black and Frances A. Bouffard. It is a member of a new class of antifungals termed the echinocandins. It wor ...
or
micafungin Micafungin, sold under the brand name Mycamine, is an echinochandin antifungal medication used to treat and prevent invasive fungal infections including candidemia, abscesses, and esophageal candidiasis. It inhibits the production of beta-1,3-g ...
is used. A number of weeks of intravenous amphotericin B may be used as an alternative. In certain groups at very high risk, antifungal medications may be used preventatively. Infections of the mouth occur in about 6% of babies less than a month old. About 20% of those receiving chemotherapy for cancer and 20% of those with
AIDS Human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV/AIDS) is a spectrum of conditions caused by infection with the human immunodeficiency virus (HIV), a retrovirus. Following initial infection an individual m ...
also develop the disease. About three-quarters of women have at least one yeast infection at some time during their lives. Widespread disease is rare except in those who have risk factors.


Signs and symptoms

Signs and symptoms of candidiasis vary depending on the area affected. Most candidal infections result in minimal complications such as redness, itching, and discomfort, though complications may be severe or even fatal if left untreated in certain populations. In healthy (
immunocompetent In immunology, immunocompetence is the ability of the body to produce a normal immune response following exposure to an antigen. Immunocompetence is the opposite of immunodeficiency (also known as ''immuno-incompetence'' or being ''immuno-comprom ...
) persons, candidiasis is usually a localized infection of the skin, fingernails or toenails (onychomycosis), or mucosal membranes, including the oral cavity and pharynx (
thrush ''The Man from U.N.C.L.E.'' is an American spy fiction television series produced by Metro-Goldwyn-Mayer Television and first broadcast on NBC. The series follows secret agents, played by Robert Vaughn and David McCallum, who work for a secret ...
), esophagus, and the genitalia ( vagina, penis, etc.); less commonly in healthy individuals, the
gastrointestinal tract The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The GI tract contains all the major organ (biology), organs of the digestive syste ...
, urinary tract, and
respiratory tract The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa. Air is breathed in through the nose to th ...
are sites of candida infection. In immunocompromised individuals, ''Candida'' infections in the esophagus occur more frequently than in healthy individuals and have a higher potential of becoming
systemic Systemic fundamental to a predominant social, economic, or political practice. This refers to: In medicine In medicine, ''systemic'' means affecting the whole body, or at least multiple organ systems. It is in contrast with ''topical'' or ''loc ...
, causing a much more serious condition, a
fungemia Fungemia is the presence of fungi or yeasts in the blood. The most common type, also known as candidemia, candedemia, or systemic candidiasis, is caused by '' Candida'' species; candidemia is also among the most common bloodstream infections of a ...
called candidemia. Symptoms of esophageal candidiasis include difficulty swallowing, painful swallowing, abdominal pain, nausea, and vomiting.


Mouth

Infection in the mouth is characterized by white discolorations in the tongue, around the mouth, and throat. Irritation may also occur, causing discomfort when swallowing. Thrush is commonly seen in infants. It is not considered abnormal in infants unless it lasts longer than a few weeks.


Genitals

Infection of the vagina or vulva may cause severe itching, burning, soreness, irritation, and a whitish or whitish-gray cottage cheese-like discharge. Symptoms of infection of the male genitalia (balanitis thrush) include red skin around the head of the penis, swelling, irritation, itchiness and soreness of the head of the penis, thick, lumpy discharge under the foreskin, unpleasant odour, difficulty retracting the foreskin ( phimosis), and pain when passing urine or during sex.


Skin

Signs and symptoms of candidiasis in the skin include itching, irritation, and chafing or broken skin.


Invasive infection

Common symptoms of gastrointestinal candidiasis in healthy individuals are anal itching, belching, bloating, indigestion, nausea, diarrhea, gas, intestinal cramps, vomiting, and
gastric ulcer Peptic ulcer disease (PUD) is a break in the inner lining of the stomach, the first part of the small intestine, or sometimes the lower esophagus. An ulcer in the stomach is called a gastric ulcer, while one in the first part of the intestines i ...
s. Perianal candidiasis can cause anal itching; the lesion can be red, papular, or ulcerative in appearance, and it is not considered to be a
sexually transmissible disease Sexually transmitted infections (STIs), also referred to as sexually transmitted diseases (STDs) and the older term venereal diseases, are infections that are spread by sexual activity, especially vaginal intercourse, anal sex, and oral sex ...
. Abnormal proliferation of the candida in the gut may lead to
dysbiosis Dysbiosis (also called dysbacteriosis) is characterized by a disruption to the microbiome resulting in an imbalance in the microbiota, changes in their functional composition and metabolic activities, or a shift in their local distribution. For ex ...
. While it is not yet clear, this alteration may be the source of symptoms generally described as the irritable bowel syndrome, and other gastrointestinal diseases.


Causes

''Candida'' yeasts are generally present in healthy humans, frequently part of the human body's normal oral and intestinal flora, and particularly on the skin; however, their growth is normally limited by the human immune system and by competition of other microorganisms, such as bacteria occupying the same locations in the human body. ''Candida'' requires moisture for growth, notably on the skin. For example, wearing wet swimwear for long periods of time is believed to be a risk factor. Candida can also cause diaper rashes in babies. In extreme cases, superficial infections of the skin or mucous membranes may enter the bloodstream and cause systemic ''Candida'' infections. Factors that increase the risk of candidiasis include HIV/
AIDS Human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV/AIDS) is a spectrum of conditions caused by infection with the human immunodeficiency virus (HIV), a retrovirus. Following initial infection an individual m ...
, mononucleosis, cancer treatments,
steroids A steroid is a biologically active organic compound with four rings arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter membrane fluidity; and a ...
, stress, antibiotic usage, diabetes, and nutrient deficiency. Hormone replacement therapy and infertility treatments may also be predisposing factors. Use of inhaled corticosteroids increases risk of candidiasis of the mouth. Inhaled corticosteroids with other risk factors such as antibiotics, oral glucocorticoids, not rinsing mouth after use of inhaled corticosteroids or high dose of inhaled corticosteroids put people at even higher risk. Treatment with antibiotics can lead to eliminating the yeast's natural competitors for resources in the oral and intestinal flora, thereby increasing the severity of the condition. A weakened or undeveloped immune system or metabolic illnesses are significant predisposing factors of candidiasis. Almost 15% of people with weakened immune systems develop a systemic illness caused by ''Candida'' species. Diets high in simple
carbohydrates In organic chemistry, a carbohydrate () is a biomolecule consisting of carbon (C), hydrogen (H) and oxygen (O) atoms, usually with a hydrogen–oxygen atom ratio of 2:1 (as in water) and thus with the empirical formula (where ''m'' may or may ...
have been found to affect rates of oral candidiases. ''C. albicans'' was isolated from the vaginas of 19% of apparently healthy people, i.e., those who experienced few or no symptoms of infection. External use of detergents or douches or internal disturbances (hormonal or physiological) can perturb the normal vaginal flora, consisting of lactic acid bacteria, such as
lactobacilli The ''Lactobacillaceae'' are a family of lactic acid bacteria. It is the only family in the lactic acid bacteria which includes homofermentative and heterofermentative organisms; in the ''Lactobacillaceae,'' the pathway used for hexose fermentati ...
, and result in an overgrowth of ''Candida'' cells, causing symptoms of infection, such as local inflammation. Pregnancy and the use of oral contraceptives have been reported as risk factors. Diabetes mellitus and the use of antibiotics are also linked to increased rates of yeast infections. In
penile A penis (plural ''penises'' or ''penes'' () is the primary sexual organ that male animals use to inseminate females (or hermaphrodites) during copulation. Such organs occur in many animals, both vertebrate and invertebrate, but males do ...
candidiasis, the causes include sexual intercourse with an infected individual, low immunity, antibiotics, and diabetes. Male genital yeast infections are less common, but a yeast infection on the penis caused from direct contact via sexual intercourse with an infected partner is not uncommon. Breast-feeding mothers may also develop candidiasis on and around the nipple as a result of moisture created by excessive milk-production. Vaginal candidiasis can cause congenital candidiasis in newborns.


Diagnosis

In oral candidiasis, simply inspecting the person's mouth for white patches and irritation may make the diagnosis. A sample of the infected area may also be taken to determine what organism is causing the infection. Symptoms of vaginal candidiasis are also present in the more common
bacterial vaginosis Bacterial vaginosis (BV) is a disease of the vagina caused by excessive growth of bacteria. Common symptoms include increased vaginal discharge that often smells like fish. The discharge is usually white or gray in color. Burning with urination ...
; aerobic vaginitis is distinct and should be excluded in the differential diagnosis. In a 2002 study, only 33% of women who were self-treating for a yeast infection actually had such an infection, while most had either bacterial vaginosis or a mixed-type infection. Diagnosis of a yeast infection is done either via microscopic examination or culturing. For identification by light microscopy, a scraping or swab of the affected area is placed on a microscope slide. A single drop of 10% potassium hydroxide (KOH) solution is then added to the specimen. The KOH dissolves the skin cells, but leaves the ''Candida'' cells intact, permitting visualization of
pseudohyphae A hypha (; ) is a long, branching, filamentous structure of a fungus, oomycete, or actinobacterium. In most fungi, hyphae are the main mode of vegetative growth, and are collectively called a mycelium. Structure A hypha consists of one or ...
and budding
yeast cell Yeasts are eukaryotic, single-celled microorganisms classified as members of the fungus kingdom. The first yeast originated hundreds of millions of years ago, and at least 1,500 species are currently recognized. They are estimated to constitu ...
s typical of many ''Candida'' species. For the culturing method, a sterile swab is rubbed on the infected skin surface. The swab is then streaked on a culture medium. The culture is incubated at 37 °C (98.6 °F) for several days, to allow development of yeast or bacterial colonies. The characteristics (such as morphology and colour) of the colonies may allow initial diagnosis of the organism causing disease symptoms. Respiratory, gastrointestinal, and esophageal candidiasis require an endoscopy to diagnose. For gastrointestinal candidiasis, it is necessary to obtain a 3–5 milliliter sample of fluid from the
duodenum The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear, and the terms anterior intestine or proximal intestine m ...
for
fungal culture A fungus ( : fungi or funguses) is any member of the group of eukaryotic organisms that includes microorganisms such as yeasts and molds, as well as the more familiar mushrooms. These organisms are classified as a kingdom, separately from th ...
. The diagnosis of gastrointestinal candidiasis is based upon the culture containing in excess of 1,000
colony-forming units In microbiology, colony-forming unit (CFU, cfu or Cfu) is a unit which estimates the number of microbial cells (bacteria, fungi, viruses etc.) in a sample that are viable, able to multiply via binary fission under the controlled conditions. Count ...
per milliliter.


Classification

Candidiasis may be divided into these types: * Mucosal candidiasis ** Oral candidiasis (thrush, oropharyngeal candidiasis) *** Pseudomembranous candidiasis *** Erythematous candidiasis *** Hyperplastic candidiasis ***
Denture-related stomatitis Denture-related stomatitis is a common condition where mild inflammation and redness of the oral mucous membrane occurs beneath a denture. In about 90% of cases, ''Candida (fungus), Candida'' species are involved, which are normally a harmless comp ...
— ''Candida'' organisms are involved in about 90% of cases *** Angular cheilitis — ''Candida'' species are responsible for about 20% of cases, mixed infection of ''C. albicans'' and ''
Staphylococcus aureus ''Staphylococcus aureus'' is a Gram-positive spherically shaped bacterium, a member of the Bacillota, and is a usual member of the microbiota of the body, frequently found in the upper respiratory tract and on the skin. It is often positive ...
'' for about 60% of cases. *** Median rhomboid glossitis ** Candidal vulvovaginitis (vaginal yeast infection) ** Candidal balanitis — infection of the glans penis, almost exclusively occurring in uncircumcised males **
Esophageal candidiasis Esophageal candidiasis is an opportunistic infection of the esophagus by ''Candida albicans''. The disease usually occurs in patients in immunocompromised states, including post-chemotherapy and in AIDS. However, it can also occur in patients wi ...
(candidal esophagitis) ** Gastrointestinal candidiasis ** Respiratory candidiasis * Cutaneous candidiasis ** Candidal
folliculitis Folliculitis is the infection and inflammation of one or more hair follicles. The condition may occur anywhere on hair-covered skin. The rash may appear as pimples that come to white tips on the face, chest, back, arms, legs, buttocks, or head. A ...
** Candidal intertrigo **
Candidal paronychia Paronychia is an inflammation of the skin around the nail, which can occur suddenly, when it is usually due to the bacterium ''Staphylococcus aureus'', or gradually when it is commonly caused by the fungus '' Candida albicans''. The term is fr ...
** Perianal candidiasis, may present as pruritus ani **
Candidid Candidid is a skin condition, an id reaction, similar to dermatophytids. See also * Candidiasis Candidiasis is a fungal infection due to any type of '' Candida'' (a type of yeast). When it affects the mouth, in some countries it is commo ...
** Chronic mucocutaneous candidiasis **
Congenital cutaneous candidiasis Congenital cutaneous candidiasis is a type of candida infection in newborn babies, which appears as generalized red patches and small bumps on the skin or in the mouth, appearing at birth or a few days after birth. It can also occur as more serio ...
** Diaper candidiasis: an infection of a child's
diaper A diaper /ˈdaɪpə(r)/ (American and Canadian English) or a nappy ( Australian English, British English, and Hiberno-English) is a type of underwear that allows the wearer to urinate or defecate Defecation (or defaecation) follows dig ...
area **
Erosio interdigitalis blastomycetica Erosio interdigitalis blastomycetica (EIB) is a skin condition caused by a Candida albicans infection, characterized by an oval-shaped area of macerated white skin on the web between and extending onto the sides of the fingers. Signs and symptoms ...
** Candidal onychomycosis (nail infection) caused by ''Candida'' *
Systemic candidiasis Invasive candidiasis is an infection (candidiasis) that can be caused by various species of Candida (fungus), ''Candida'' yeast. Unlike ''Candida'' infections of the mouth and throat (oral candidiasis) or vagina (candidal vulvovaginitis, ''Candi ...
** Candidemia, a form of
fungemia Fungemia is the presence of fungi or yeasts in the blood. The most common type, also known as candidemia, candedemia, or systemic candidiasis, is caused by '' Candida'' species; candidemia is also among the most common bloodstream infections of a ...
which may lead to sepsis **
Invasive candidiasis Invasive candidiasis is an infection (candidiasis) that can be caused by various species of ''Candida'' yeast. Unlike ''Candida'' infections of the mouth and throat (oral candidiasis) or vagina ( ''Candidal'' vulvovaginitis), invasive candidias ...
(disseminated candidiasis) — organ infection by ''Candida'' ** Chronic systemic candidiasis (hepatosplenic candidiasis) — sometimes arises during recovery from
neutropenia Neutropenia is an abnormally low concentration of neutrophils (a type of white blood cell) in the blood. Neutrophils make up the majority of circulating white blood cells and serve as the primary defense against infections by destroying bacteria ...
*
Antibiotic candidiasis Candidiasis is a Fungal infection in animals, fungal infection due to any type of ''Candida (genus), Candida'' (a type of yeast). When it Oral candidiasis, affects the mouth, in some countries it is commonly called thrush. Signs and symptoms in ...
(iatrogenic candidiasis)


Prevention

A diet that supports the immune system and is not high in simple carbohydrates contributes to a healthy balance of the oral and intestinal flora. While yeast infections are associated with diabetes, the level of blood sugar control may not affect the risk. Wearing cotton underwear may help to reduce the risk of developing skin and vaginal yeast infections, along with not wearing wet clothes for long periods of time. For women who experience recurrent yeast infections, there is limited evidence that oral or intravaginal probiotics help to prevent future infections. This includes either as pills or as yogurt. Oral hygiene can help prevent oral candidiasis when people have a weakened immune system. For people undergoing cancer treatment, chlorhexidine mouthwash can prevent or reduce thrush. People who use inhaled corticosteroids can reduce the risk of developing oral candidiasis by rinsing the mouth with water or mouthwash after using the inhaler. People with dentures should also disinfect their dentures regularly to prevent oral candidiasis.


Treatment

Candidiasis is treated with antifungal medications; these include
clotrimazole Clotrimazole, sold under the brand name Lotrimin, among others, is an antifungal medication. It is used to treat vaginal yeast infections, oral thrush, diaper rash, tinea versicolor, and types of ringworm including athlete's foot and jock itch ...
, nystatin, fluconazole,
voriconazole Voriconazole, sold under the brand name Vfend among others, is an antifungal medication used to treat a number of fungal infections. This includes aspergillosis, candidiasis, coccidioidomycosis, histoplasmosis, penicilliosis, and infections by '' ...
, amphotericin B, and
echinocandin Echinocandins are a class of antifungal drugs that inhibit the synthesis of β-glucan in the fungal cell wall via noncompetitive inhibition of the enzyme 1,3-β glucan synthase. The class has been termed the " penicillin of antifungals," along ...
s. Intravenous fluconazole or an intravenous echinocandin such as
caspofungin Caspofungin (INN) (brand name Cancidas) is a lipopeptide antifungal drug from Merck & Co., Inc. discovered by James Balkovec, Regina Black and Frances A. Bouffard. It is a member of a new class of antifungals termed the echinocandins. It wor ...
are commonly used to treat immunocompromised or critically ill individuals. The 2016 revision of the clinical practice guideline for the management of candidiasis lists a large number of specific treatment regimens for ''Candida'' infections that involve different ''Candida'' species, forms of antifungal drug resistance, immune statuses, and infection localization and severity. Gastrointestinal candidiasis in immunocompetent individuals is treated with 100–200 mg fluconazole per day for 2–3 weeks.


Localized infection

Mouth and throat candidiasis are treated with antifungal medication. Oral candidiasis usually responds to topical treatments; otherwise, systemic antifungal medication may be needed for oral infections. Candidal skin infections in the skin folds (candidal intertrigo) typically respond well to topical antifungal treatments (e.g., nystatin or miconazole). For breastfeeding mothers topical miconazole is the most effective treatment for treating candidiasis on the breasts. Gentian violet can be used for thrush in breastfeeding babies. Systemic treatment with antifungals by mouth is reserved for severe cases or if treatment with topical therapy is unsuccessful. Candida esophagitis may be treated orally or intravenously; for severe or azole-resistant esophageal candidiasis, treatment with amphotericin B may be necessary. Vaginal yeast infections are typically treated with topical antifungal agents. Penile yeast infections are also treated with antifungal agents, but while an internal treatment may be used (such as a pessary) for vaginal yeast infections, only external treatments – such as a cream – can be recommended for penile treatment. A one-time dose of fluconazole by mouth is 90% effective in treating a vaginal yeast infection. For severe nonrecurring cases, several doses of fluconazole is recommended. Local treatment may include vaginal
suppositories A suppository is a dosage form used to deliver medications by insertion into a body orifice where it dissolves or melts to exert local or systemic effects. There are three types of suppositories, each to insert into a different sections: rectal su ...
or medicated douches. Other types of yeast infections require different dosing. ''C. albicans'' can develop resistance to fluconazole, this being more of an issue in those with HIV/AIDS who are often treated with multiple courses of fluconazole for recurrent oral infections. For vaginal yeast infection in pregnancy, topical imidazole or
triazole A triazole is a heterocyclic compound featuring a five-membered ring of two carbon atoms and three nitrogen atoms with molecular formula C2H3N3. Triazoles exhibit substantial isomerism, depending on the positioning of the nitrogen atoms within t ...
antifungals are considered the therapy of choice owing to available safety data. Systemic absorption of these topical formulations is minimal, posing little risk of
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