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 immunosuppressed, as systemic illness in this group may be more likely and particularly serious.

Referral

• The British National Formulary recommends referral for investigation if candidal infection fails to respond to 1–2 weeks of treatment [BNF 57, 2009].
• People who have chronic or recurrent oral candidal infection because of concomitant use of immunosuppressive drugs require specialist care and management options.
• 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.