Oral Candidiasis in Infants

Background

• Oral candidiasis is a superficial fungal infection of the oral mucosa caused by overgrowth of Candida species.
  • It is caused by members of the genus Candida, primarily Candida albicans, which are dimorphic fungi that can grow as yeast or as filaments (hyphae).
  • It is the most common oral fungal infection in infants and usually manifests as acute pseudomembranous candidiasis (thrush), but acute atrophic candidiasis or angular cheilitis can also occur.
• Oral candidiasis usually presents as loosely attached white or white yellow plaques with erythematous base on the tongue, buccal mucosa, hard and soft palates, and/or oropharynx. Irritability, decreased oral intake, and/or feeding refusal may also be present.

Evaluation

• Plaques from oral candidiasis may be difficult to remove and if removed, the underlying surface may be raw, erythematous, and bleeding.
• The diagnosis can be made without testing when the characteristic oral lesions are present.
• Consider microscopic examination of lesion scraping if the infant is unresponsive to treatment or immunocompromised.

Management

• Topical nystatin suspension:
  • Use topical nystatin suspension for the treatment of mild/uncomplicated oral candidiasis in otherwise healthy infants or infants with HIV infection (Strong recommendation).
  • Administer nystatin 100,000 units (1 mL) in each side of mouth (200,000 units [2 mL] total) 4 times daily for 7-14 days (at least 48 hours after the resolution of perioral symptoms). May consider 50,000 units (0.5 mL) in each side of mouth (100,000 units [1 mL] total) orally 4 times daily in premature or low-birth-weight infants.
• Oral fluconazole:
  • Use oral fluconazole for infants with oral candidiasis that is resistant to or recurrent after topical antifungals, for moderate or severe oral candidiasis in infants with HIV infection, or in other immunocompromised infants (Strong recommendation).
  • Prescribe 6 mg/kg orally on day 1 (maximum 400 mg/dose), then 3 mg/kg orally once daily for a total of ≥ 14 days in infants ≥ 6 months old. Dosing interval may be different in premature infants and infants aged 0-5 months.
  • Itraconazole oral solution 2.5 mg/kg (maximum 200-400 mg/dose) orally twice daily for 7-14 days can be used as an alternative (Strong recommendation).
• For fluconazole-resistant disease, use itraconazole oral solution 2.5 mg/kg (maximum 200-400 mg/dose) orally twice daily for 7-14 days (Strong recommendation).
• For immunocompromised infants:
  • Use antiretroviral therapy in children with HIV infection (Strong recommendation).
  • For the treatment of uncomplicated candidiasis, give topical nystatin for 7-14 days (Strong recommendation).
  • For moderate or severe disease, treat with fluconazole 6-12 mg/kg (maximum 400 mg/dose) orally once daily for 7-14 days (Strong recommendation).
  • For fluconazole-refractory disease, consider itraconazole oral solution 2.5 mg/kg (maximum 200-400 mg/day) orally twice daily for 7-14 days (Weak recommendation).
• For chronic suppressive therapy, give fluconazole 6-12 mg/kg (maximum 600 mg/dose) orally 3 times weekly but this is typically not required (Strong recommendation).