Candidiasis Superficial in Neonates and Children

Publication: 01/03/2009  
Last review: 16/08/2018  
Next review: 16/08/2021  
Clinical Guideline
CURRENT 
ID: 1549 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the management of Superficial candidiasis in Neonates and children

Summary
Candidiasis Superficial in Neonates and Children

Diagnostic criteria

  • Criteria for use of guidelines
    • Neonates and children either at risk of or diagnosed with Candida infection

Investigations

See main guideline

Treatment

See main guideline

Aims

  • To improve the diagnosis, investigation, management of Superficial candidiasis (oral and cutaneous disease) in neonates and children

Objectives

  • To provide evidence-based recommendations for appropriate investigation of Superficial candidiasis (oral and cutaneous disease) in neonates and children
  • To provide evidence-based recommendations for appropriate antimicrobial therapy of Superficial candidiasis (oral and cutaneous disease) in neonates and children
  • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
  • To advise in the event of antimicrobial allergy.
  • To set out criteria for referral for surgery or specialist input.

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Background

Invasive fungal infection cause a significant disease burden in NICUs worldwide, with mortality rates recorded as high as 44%.1 The most common fungi causing invasive infection in neonates are Candida species, which account for up to 12% of late-onset sepsis in very low birth weight (VLBW) infants (<1500g).2 Non-specific clinical features, poor sensitivity of diagnostic tests, and late recognition mean that at the time of diagnosis invasive fungal infection is often advanced. VLBW neonates are at risk of invasive fungal infection because of their immature immune system and the invasive supportive care they receive. Other risk factors include prior exposure to broad spectrum antibiotics, indwelling central venous catheters, parenteral nutrition and corticosteroid therapy.4

The antifungal treatment regimens used in the United Kingdom are similar to those reported from North America.5 At present there is insufficient evidence to favour one antifungal agent over another for treating VLBW infants with invasive fungal infection.6 Currently the clinical choice of therapy may be affected by concerns about the risk of toxicity associated with the various drugs. For example, in some patients, evidence exists that renal toxicity is higher with conventional amphotericin B than with lipid complex formulations or with azole drugs. However, there are only a few observational data on the relative risks of toxicity of antifungal drugs in VLBW infants.5

Studies have shown that colonisation with Candida spp. is an important risk factor for subsequent infection.7 Prophylactic fluconazole has been shown to reduce the incidence of colonisation and invasive Candida infection in this population.3 The infectious disease Society of America (IDSA) has published a consensus statement on the treatment of candidiasis.7

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Clinical Diagnosis

1) Cutaneous Candidiasis (nappy rash)

  • Discrete red spots around the perineum. May be confluent in areas. Usually not vesicular. May be worse in the skin creases. If severe may cause excoriation. Look for clinical evidence of oral candidiasis which often co-exists.
  • Treatment should not be initiated on clinical grounds alone. There are many causes of nappy rash and it is not always possible to identify such cases accurately. The costs of diagnostic tests are small relative to inappropriate and unnecessary treatment.

2) Oral Candidiasis (Oral thrush)

  • White plaques within the oral cavity. Often bleed slightly when scraped off. Need to distinguish from furring of the tongue after milk feeds.
  • Look for clinical evidence of perineal candidiasis which often co-exists.
  • Erythematous oral candidiasis - Presents with marked soreness and erythema particularly on the dorsum of the tongue. It is most common after treatment with oral antibiotics.
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Investigation

1) Cutaneous Candidiasis (nappy rash)

  • A skin swab should be sent to microbiology to confirm the diagnosis and exclude other causes of infection.
  • If not responding to treatment after 1 week or if diagnostic uncertainty send repeat swab to microbiology. State on form whether on any antifungal or antibiotic treatment.

2) Oral Candidiasis (Oral thrush)

  • Send swab to microbiology to confirm diagnosis
  • If severe, persistent or recurrent consider checking immune function.

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Treatment

1) Cutaneous Candidiasis (nappy rash)

  • First line therapy is miconazole 2% cream (Daktarin).
  • Apply miconazole 2% cream twice daily for 10 days after lesions have healed
  • Oral therapy is not required in the absence of oral involvement, unless the disease is severe or generalised, in which case systemic antifungal therapy is required (see “Invasive Candidiasis”).

2) Oral Candidiasis (Oral thrush)

  • First line therapy consists of nystatin suspension (100 000 units/ml). Give 1ml QDS. Continue for 5 days or until lesions have resolved.
  • Second line therapy is miconazole gel (20mg/g) (Daktarin). Note that a small amount of miconazole is absorbed when given by this route, which may cause side effects (e.g. elevated liver enzymes). 2.5ml of gel should be used 2 - 4 times a day after feeds
  • Topical perineal therapy is not required in the absence of a perineal rash.

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Provenance

Record: 1549
Objective:
  • To provide evidence-based recommendations for appropriate investigation of Superficial candidiasis (oral and cutaneous disease) in neonates and children
  • To provide evidence-based recommendations for appropriate antimicrobial therapy of Superficial candidiasis (oral and cutaneous disease) in neonates and children
  • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
  • To advise in the event of antimicrobial allergy.
  • To set out criteria for referral for surgery or specialist input.
Clinical condition:

Superficial candidiasis

Target patient group: Neonates and children presenting with superficial candidiasis
Target professional group(s): Pharmacists
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Amended May 2011 to include children.


Evidence base

References

  1. Healy et al. Fluconazole Prophylaxis in Extremely Low Birth Weight Neonates Reduces Invasive Candidiasis Mortality Rates Without Emergence of Fluconazole-Resistant Candida Species. Pediatrics 2008;121;703-710
  2. Stoll et al. Late-onset sepsis in VLBW neonates: the experience of the NICHD Neonatal Research Network. Pediatrics 2002; 110(2);285-291
  3. Manzoni et al. A Multicentre, Randomized Trial of Prophylactic Fluconazole in Preterm Neonates. N Engl J med 356;24: 2483-249
  4. Kicklighter et al. Fluconazole for Prophylaxis Against Candidal Rectal Colonisation in the VLBW Infant. Paediatrics 2001;107:293-8
  5. L Clerihew, T L Lamagni, P Brocklehurst, and W McGuire
    Invasive fungal infection in very low birthweight infants: national prospective surveillance study. Arch. Dis. Child. Fetal Neonatal Ed 2006
  6. Clerihew L, McGuire W. Systemic antifungal drugs for invasive fungal infection in preterm infants. Cochrane Database Syst Rev 2004;1
  7. Pappas PG et al. Guidelines for the treatment of candidiasis.
  8. Makhoul et al. Review of 49 Neonates with acquired fungal sepsis: further characterization. Paediatrics 2001; 107:61-66
  9. Rex JH, Walsh, TJ, Sobel JD. Practice guidelines for the treatment of candidiasis.
  10. Karlowicz, MG et al. Should central venous catheters be removed as soon as candidaemia is detected in neonates? Pediatrics 2000;106(5) e63
  11. McGuire W, Clerihew L, Austin N. Prophylactic intravenous antifungal agents to prevent mortality and morbidity in very low birth weight infants (Cochrane review). In The Cochrane Library, issue 1, 2003. Oxford: Updated software.
  12. F Adler-Shohet, H Waskin, and J M Lieberman. Amphotericin B lipid complex for neonatal invasive candidiasis. Arch. Dis. Child. Fetal Neonatal Ed., 2001; 84: 131 - 133.
  13. N. Linder, G. Klinger, I. Shalit, I. Levy, S. Ashkenazi, G. Haski, O. Levit, and L. Sirota
    Treatment of candidaemia in premature infants: comparison of three amphotericin B preparations. J. Antimicrob. Chemother. 2003; 52(4): 663 - 667.
  14. D. Kaufman and K. D. Fairchild. Clinical Microbiology of Bacterial and Fungal Sepsis in Very-Low-Birth-Weight Infants. Clin. Microbiol. Rev.2004; 17(3): 638 - 680.
  15. H Smith and P Congdon. Neonatal systemic candidiasis. Arch. Dis. Child. 1985; 60: 365 - 369.
  16. Huttova M, Hartmanova I, Kralinsky K, et al. Candida fungemia in neonates treated with fluconazole: report of forty cases, including eight with meningitis. Pediatr Infect Dis J.1998; 17 :1012 –1015
  17. L Clerihew, T L Lamagni, P Brocklehurst, and W McGuire. Candida parapsilosis infection in very low birthweight infants. Arch. Dis. Child. Fetal Neonatal Ed.2007; 92(2): 127 - 129.

NB – This last article states that C. parapsilosis is best treated with Ambisome but this doesn’t conform to previous guidelines??

Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

Not supplied

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