Recommendations for the assessment and treatment of oral candidal infection are in line with expert opinion from a textbook [Hay and Moore, 2004] and narrative reviews [Akpan and Morgan, 2002; Gonsalves et al, 2007; Samaranayake et al, 2009].

Admission

• Systemic candidiasis, or candidiasis spreading to the oesophagus, is a life-threatening infection requiring immediate intervention by specialists [Pappas et al, 2009]. Systemic candidiasis has an estimated mortality rate of 71–79% [Akpan and Morgan, 2002]. It is reasonable to maintain a low threshold for admission in people who are immunocompromised as systemic illness in this group may be particularly serious.

Fluconazole

• Fluconazole has a broad range of antifungal activity, including against candida species [Pappas et al, 2009; Samaranayake et al, 2009]. It is recommended as first-line treatment in people who are HIV-positive.
• There is good evidence from several randomized controlled trials (RCTs) that, in the treatment of people with oral candidal infection who are HIV-positive, fluconazole is more effective than nystatin and clotrimazole, and there is conflicting evidence that it is equally effective or more effective than oral ketoconazole [Pienaar et al, 2006].
• Fluconazole is systemically absorbed, which is an advantage for widespread candidal infection.

Drugs not recommended

• Topical drugs (or drugs that are poorly absorbed), are not recommended because evidence from RCTs suggests they are not as effective as systemic drugs [Pienaar et al, 2006].

Drugs not recommended for initiation in primary care

• Oral itraconazole should be reserved for cases of fluconazole-resistant candidiasis [BNF 57, 2009]. Specialist advice should be obtained before initiating itraconazole therapy because of the increased risk of drug interactions and adverse effects.
• Oral ketoconazole should only be prescribed for the treatment of chronic mucocutaneous candidiasis that cannot be treated topically because of the site, extent of the lesion, or deep infection of the skin, and in people resistant to or intolerant of both fluconazole and itraconazole [MHRA, 2008].
• Oral amphotericin is not recommended as there is a lack of trial evidence of efficacy in the treatment of oral candidiasis. It is sometimes used as an adjunct to other systemic antimycotic drugs [Laudenbach and Epstein, 2009].

Admission

• Systemic candidiasis, or candidiasis spreading to the oesophagus, is a life-threatening infection requiring immediate intervention by specialists [Pappas et al, 2009]. Systemic candidiasis has an estimated mortality rate of 71–79% [Akpan and Morgan, 2002]. It is reasonable to maintain a low threshold for admission in people who are immunocompromised, as systemic illness in this group may be particularly serious.

Referral

• The British National Formulary recommends referral for investigation if candidal infection fails to respond to 1–2 weeks treatment [BNF 57, 2009].
• People who have chronic or recurrent oral candidal infection because of concomitant use of immunosuppressive drugs require specialist care.
• Infection that is unresponsive to fluconazole, or breakthrough candidiasis while taking preventive treatment, may indicate the development of resistance, the presence of a resistant organism (such as Candida glabrata or Candida krusei) or bacterial superinfection [Samaranayake et al, 2009]. It may be reasonable to swab for the presence of resistant organisms in this group [Akpan and Morgan, 2002].
• Chronic plaque-like oral candidiasis may be a feature of premalignant change [Samaranayake et al, 2009]. Biopsy may be indicated, especially if it is unresponsive to treatment.