Candida infections of the lungs: Diagnosis and treatment

Article written by microbiologists - Laboratory Department - Vinmec Central Park International General Hospital

Candida albicans is a yeast that commonly causes infections in many parts of the human body, including the lungs. Accordingly, Candida fungus causes many dangerous complications for the lungs, so patients need to be diagnosed and treated promptly.

Candida albicans is the most common yeast infection in the Candida family. These are very common fungi, living everywhere, on the human body candida usually occurs in the skin, mouth, gastrointestinal tract and genital area. . Normally, candida will live in balance with other microorganisms in the body without causing harm, with about 15% to 30% of healthy people carrying Candida in the mouth and throat and 15% in the bronchi. However, when conditions are favorable, candida will have the opportunity to thrive and cause disease in many other parts of the body.

Isolates of Candida species from the respiratory tract are common in patients in the ICU and undergoing chronic tracheostomy or tracheostomy. This nearly always reflects airway invasion and absence of infection. Candida pneumonia and lung abscesses are rare, and only a few cases of primary pneumonia or abscess have been reported after oropharyngeal aspiration.
Candida pneumonia is generally limited to severely immunocompromised patients who develop the infection after spreading from the bloodstream to the lungs. CT scan of the chest often shows multiple lung nodules.
Candida albicans lung disease: Candida albicans is one of the candida species that often causes disease in humans when the body is immunocompromised due to causes or prolonged aerosols of antibiotics. Fungal pneumonia accounts for a small part of pneumonia and Candida is the most common cause of invasive fungal infections, accounting for 70-90%. Fungi can reside in the body without causing disease or can cause real disease, especially in immunocompromised sites.
Bronchial fungal: Common in young children due to fungus in the throat, mouth is inhaled into the bronchi.

Clinical symptoms following Candida infection are as follows:
Fever, cough (usually without phlegm) Pleural chest pain or discomfort Progressive dyspnea leading to respiratory failure Symptoms of airway obstruction compressed mediastinal ganglion respiration in epidemiological fungal diseases. Coagulation of the lung - Scrubbing of the pleura. Mushrooms localized in the lungs: Can be localized or diffuse, the course of the disease is acute, subacute or chronic: Clinical presentation of the acute form resembles pneumonia, high fever 39 degrees Celsius, intermittent cough, sputum with particles Gray, yellow, stick together to form a clot, the patient often coughs up blood and may have respiratory failure.
X-ray picture of the lungs : Picture of infiltrates like pneumonia, can be on one lung (local form) or in both lungs like picture of bronchi - bronchiolitis
Fungus in the bronchi: Common in young children due to pneumonia fungus in the throat, mouth is inhaled into the bronchi. Clinical manifestation is that the patient has chest pain, sputum and blood, sometimes dyspnea like bronchial asthma due to allergy to fungi. Bronchoscopy showed scattered white patches, pseudomembranous membranes, red inflamed bronchial mucosa.

White blood cell count (BC): may be increased in healthy individuals with epidemiological Eosinophilia: may increase, achieving a higher chance of opportunistic fungal infections with Candida or Aspergillus

Specimens need to be transported, handled and inoculated properly. Detect mycelium or yeast.

From respiratory samples in a severely immunosuppressed patient, isolate the organism from bronchoalveolar lavage (BAL) and respiratory tract samples. Blood cultures confirm Candida species/B dermatitidis when the patient has disseminated fungal infection.

Based on histopathological examination of invasive disease. Therefore, bronchial biopsy, transbronchial biopsy are valuable diagnostic methods. Flexible bronchoscopy: Gram-stained PQPN wash, fungal culture and transbronchial biopsy

Candidiasis is a yeast infection caused by fungi of the Candida family, which are mostly caused by the fungus Candida albicans.

Recommendations
The growth of Candida from respiratory secretions is usually exaggerated and rarely requires antifungal therapy (strong recommendation; moderate-quality evidence).
Summary of evidence
Although the diagnosis of Candida pneumonia is supported by isolation of the organism from bronchoalveolar lavage (BAL) specimens, a definitive diagnosis requires histopathological evidence of invasive disease. encroachment.
Prospective and retrospective autopsy studies consistently demonstrate poor predictive value of Candida growth from respiratory secretions, including BAL.
In a prospective study, none of the 77 patients died in an ICU and had clinical and radiological evidence of pneumonia and culture was positive for Candida from the BAL or sputum demonstrating evidence of Candida inflammation. lungs at autopsy. Because of the rarity of Candida pneumonia, the extremely common finding of Candida in respiratory secretions, and the lack of specificity of this finding, the decision to initiate antifungal therapy should not be made on the basis of Based on the results of respiratory culture alone.
Recent observations suggest that airway colonization with Candida species is associated with bacterial growth and pneumonia. Invasive airway candidiasis was also associated with worse clinical outcomes and higher mortality in these studies. However, it is unclear if airway Candida isolates have a causal relationship with poorer outcomes or are simply an indicator of disease severity.

Recommendations
For mild disease: clotrimazole, 10 mg lozenges 5 times daily, OR miconazole 50 mg tablets applied to the mucosal surface of canines once daily for 7-14 days, recommended (recommended) strong; high-quality evidence).
Alternatives for mild disease include nystatin suspension (100 000 U/mL) 4 -6 mL/ 4 times/day, OR 1-2 ampoules of nystatin (200 000 U/mL) x 4 times/day, for 7-14 days (strong recommendation; moderate-quality evidence).
For moderate to severe disease, oral fluconazole, 100-200 mg daily, for 7-14 days is recommended (strong recommendation; high-quality evidence).
For fluconazole intolerance, itraconazole solution, 200 mg once daily OR posaconazole solution, 400 mg twice daily for 3 days then 400 mg daily, for up to 28 days, is recommended (strong recommendation; moderate quality evidence).
Alternatives for fluconazole intolerance include voriconazole, 200 mg twice daily, OR AmB deoxycholate oral suspension, 100 mg/mL x 4 times daily (strong recommendation; moderate-quality evidence ).
Intravenous echinocandin (caspofungin: 70 mg initially, then 50 mg/day; micafungin: 100 mg/day; or anidulafungin: 200 mg initially, then 100 mg/day) OR AmB deoxycholate IV, 0 ,3 mg/kg/day, as an alternative for disease intolerance (weak recommendation; moderate-quality evidence).
Chronic suppressive therapy is usually not needed. If necessary for patients with recurrent infections, fluconazole, 100 mg 3 times/week, is recommended (strong recommendation; high evidence).
For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce the rate of infection recurrence (strong recommendation; high-quality evidence).
For denture-associated Candida infections, denture sterilization, in addition to antifungal therapy, is recommended (strong recommendation; moderate-quality evidence).
Summary of evidence
Oropharyngeal and esophageal candidiasis occurs in association with HIV infection, diabetes, leukemia and other malignancies, steroid use, radiation therapy, antibacterial therapy, and dental use pseudotypes, and their presence is recognized as an indicator of immune dysfunction. In HIV-infected patients, oropharyngeal candidiasis is commonly observed in patients with CD4 counts <200 cells/mL. The advent of effective antiviral therapy has led to a dramatic decrease in the incidence of oropharyngeal candidiasis and a marked decrease in refractive disease cases.
Resistance to fluconazole or multiazole is mainly a consequence of long-term and repeated exposure to fluconazole or other azoles. Especially in patients with advanced immunosuppression and low CD4 counts, resistance to C. albicans has been described, as has the gradual emergence of Candida non albicans species, especially C. glabrata, as a cause of mucosal candidiasis intolerance.
Most oropharyngeal candidiasis infections are caused by C. albicans, either alone or with a mixed infection. Symptomatic infections caused by C. glabrata , C. dubliniensis and C. krusei alone have been described.
Many randomized prospective studies of oropharyngeal candidiasis have been performed involving AIDS and cancer patients. Most patients will respond initially to topical treatment. In HIV-infected patients, symptom recurrence was earlier and more frequent with topical treatment with fluconazole. In a randomized multicenter study in HIV-infected individuals, 50 mg of miconazole mucilage lozenges applied once daily to the sublingual mucosa was as effective as 10 mg of clotrimazole troches administered 5 times daily. . Fluconazole and itraconazole solution are superior to ketoconazole and itraconazole capsules.
Posaconazole solution is as effective as fluconazole in AIDS patients. Posaconazole, 100 mg, 300 mg delayed-release tablets as a single dose, is FDA-approved for the prophylaxis of fungal infections in high-risk patients. The tablets provide stable bioavailability (about 55%), take once daily, and are less convenient than strict food requirements for absorption. This formulation has not been fully evaluated for mucosal candidiasis, but with further research, an oral solution may be substituted for this purpose.
Recurrent infections often occur in patients with prolonged immunosuppression, especially those with AIDS and low CD4 cell counts (<50 cells/μL). Long-term treatment with an inhibitor with fluconazole has been shown to be effective in the prevention of oropharyngeal candidiasis. In a large multicenter study of HIV-infected patients, long-term suppressive therapy with fluconazole was compared with routine use of fluconazole in response to epidemic symptoms.
Continuous inhibitory treatment is more effective at reducing relapse rates than intermittent treatment, but is associated with increased resistance in vitro. The frequency of disease recurrence was the same for both groups.
AmB oral deoxycholate, nystatin solution, and itraconazole capsules are less effective than fluconazole in preventing oropharyngeal candidiasis. Infections with intolerance to fluconazole should be treated initially with itraconazole solution; 64% to 80% of patients will respond to this therapy. Posaconazole suspension is effective in approximately 75% of patients with recurrent oropharyngeal or esophageal candidiasis, and voriconazole is also effective for fluconazole-intolerant infections. Intravenous caspofungin, micafungin and anidulafungin have shown to be effective alternatives to the azole intolerance agents
AmB deoxycholate topically or intravenously has also been effective in some patients; however, pharmacists must prepare according to oral formulations. Immune to granulocyte-promoting factor, macrophage, or interferon, sometimes used in the management of oral candidiasis and drug intolerance.
Reduces the incidence of oral candidiasis and the frequency of symptomatic oropharyngeal candidiasis in HIV-infected patients on effective antiretroviral therapy. Therefore, antiretroviral therapy should be used whenever possible for HIV-infected patients with oropharyngeal or esophageal candidiasis.
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