Candidiasis
Overview
- Candida species can be normal flora and therefore not need treatment if asymptomatic
- Can be sexually transmitted but is not considered an STI
- Can arise spontaneously or secondary to disturbance of vaginal flora e.g. antibiotic therapy.
Cause
Majority Candida albicans, rarely other candida species.
Clinical presentation
| Male | Female |
| Symptoms | |
|
Red rash on genitals, especially under foreskin, may or may not be itchy |
White ‘curd like’ vaginal discharge although discharge can appear normal |
|
Swelling of foreskin if severe |
Genital/vulval itch, discomfort |
| Fissures Superficial erosions |
Superficial dysparuenia External dysuria Excoriation, erythema, fissures, swelling |
| Complications | |
| n/a | n/a |
Special considerations
Recurrent candidiasis is defined as 4 or more episodes in a 12 month period. It occurs in <5% of women and should be confirmed by culture and other causes for symptoms must be excluded by genital examination. Important to exclude diabetes mellitus, HIV infection or other causes if immunosuppression.
Diagnosis
In men, usually diagnosed on basis of symptoms and signs.
| Diagnosis in males | ||
|---|---|---|
| Test | Site/Specimen | Consideration |
| Microscopy and culture |
Penis |
Culture for yeast. May be negative in cases that respond to presumptive therapy. |
| Diagnosis in females | ||
|---|---|---|
| Test | Site/Specimen | Consideration |
| Microscopy and culture |
High vaginal swab or self-collected vaginal swab |
Culture for yeast |
| Gram stain microscopy, if available, for point of care diagnosis |
High vaginal swab or self-collected vaginal swab |
Enables immediate treatment and differentiation of candida from bacterial vaginosis or trichomoniasis |
Specimen collection
Urethral swabs for microscopy should be collected when the patient has not urinated for at least 1 hour and only if the patient has frank urethral discharge. Squeeze the urethra to express the discharge and collect on urethral swab. It is not necessary to insert the swab into the urethra. Vaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient.Clinician collected for NAAT/culture/microscopy
Rectal swabs should be collected by inserting a sterile swab 2-4cms into the anal canal and moving the swab gently side to side for 10-20 seconds.
Pharyngeal swabs should be collected from the tonsils and oropharynx.
High vaginal swab of vaginal discharge smeared onto a glass slide, air dried and sent for microscopy. Swab inserted into transport medium for culture.Self-collection of samples for NAAT testing
Investigations
- Recurrent candidiasis should be confirmed with vaginal swab for microscopy and culture
- Consider non-albicans species
- Consider testing for herpes only if there are clinical signs and symptoms
- Exclude diabetes mellitus
- Exclude HIV infection if recurrent and severe symptoms.
See STI Atlas for images.
Management
| Principal Treatment Options | ||
|---|---|---|
| Situation | Recommended | Alternative |
| Uncomplicated |
Vaginal azole creams (e.g. clotrimazole 10% vaginal cream, 1 applicatorful intravaginally at night, as stat dose or 3-7 day course) |
Fluconazole 150mg PO, stat |
| Recurrent Candida albicans |
Treat each episode with longer course of azole cream (rather than stat dose) and/or induction with fluconazole 150mg PO, for 3 doses, 3 days apart, followed by maintenance with fluconazole 100mg PO, weekly for 6 months |
Itraconazole 100mg PO, daily until asymptomatic then 100mg weekly for 6 months |
| Candida glabrata |
Boric acid 600mg vaginal pessaries (from a compounding pharmacy), 1 nocte for 14 days |
|
Treatment advice
- Intravaginal and oral azoles have a similar efficacy
- The addition of hydrocortisone 1% cream may provide symptomatic relief
- No evidence that specific diets, or use of probiotics influence recurrence of candidiasis
- Reconsider diagnosis in men, if no response to therapy
- Oral azoles cannot be used in pregnancy.
Other immediate management
- Avoid local irritants e.g. soaps bath oils body washes, bubble baths, spermicides, vaginal lubricants, vaginal hygiene products
- Latex condoms, diaphragms and cervical caps can be damaged by antifungal vaginal creams
- Male sexual partners only require treatment if symptomatic.
Special treatment situations
Special considerations
Consider seeking specialist advice before treating any complicated presentation.
| Situation | Recommended | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Pregnant women
For more information go to the Therapeutic Goods Association's Prescribing medicines in pregnancy database and/or seek specialist advice.  |
Fluconazole contraindicated. May need longer course of topical treatment. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Allergy to principal treatment choice |
Try alternative treatment. |
Contact tracing
Contact tracing is not required.
Follow up
Not indicated for uncomplicated infection.
If STI confirmed, follow up provides an opportunity to:
- Confirm patient adherence with treatment and assess for symptom resolution.
- Confirm contact tracing has been undertaken or offer more contact tracing support.
- Provide further sexual health education and prevention counselling.
Test of Cure (TOC)
Not required.
Retesting
Not indicated unless symptoms fail to resolve. Consider testing for other STIs, if not undertaken at first presentation, or retesting post the window period.
Auditable outcomes
100% of patients with recurrent candida have had yeast cultures and genital examination performed to inform further treatment.