Candidiasis

thrush | candida |

Overview

  • Candida species can be normal flora and therefore not need treatment if asymptomatic
  • Not sexually transmitted
  • Can arise spontaneously or secondary to disturbance of vaginal flora e.g. antibiotic therapy.

Cause

Candida albicans and other candida species more rarely.

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. 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
TestSite/SpecimenConsideration
Microscopy and culture

Penis

Culture for yeast.

May be negative in cases that respond to presumptive therapy.

 

Diagnosis in females
TestSite/SpecimenConsideration
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 

Clinician collected
Self-collection

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
SituationRecommendedAlternative
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.

SituationRecommended
Pregnant women 
pregnancy
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 performed to inform further treatment.

Last Updated: Tuesday, 22 March 2016