This is a common scenario among our hospitalized patients with indwelling catheters, prior antibiotic therapy or diabetes mellitus who seem to have no clinical signs of infection. Fortunately, candidemia from urinary sources appears uncommon to rare, with up to nearly ½ of patients clearing their candiduria with removal of the indwelling catheter alone (1). The Infectious Diseases Society of America guidelines do not recommended treatment of asymptomatic candiduria unless the patient belongs to a group at high risk of dissemination, such as severely immunosuppressed or neutropenic patients, infants with low birth weight, and patients who will undergo urologic manipulation (2). Supporting such recommendation is a retrospective long-term follow-up of patients with candiduria demonstrating no significant improvement in rates of recurrences of candiduria or candidemia with treatment (3). Fluconazole is usually considered the first-line agent of choice when treatment is indicated.
1. Kauffman CA. Candiduria. Clin Infect Dis 2005;41:S371-6.
2. Pappas PG, Kauffman CA, Andes D, et al. Clinical Practice Guidelines for the Management of Candidiasis: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 48:503–35.
3. Revankar SG, Hasan MS, Revankar VS, et al. Long-term follow-up of patients with candiduria. Eur J Clin Microbiol Infect Dis 2011;30:137-140.
Chances are our patient has been on antibiotics and is being treated with either inhaled and/or systemic corticosteroids which may all contribute to yeast overgrowth in the respiratory and GI tracts. Fortunately, in the absence of severe immunocompromised state such as neutropenia, Candida sp. in respiratory specimens (including those obtained by bronchoscopy) is only rarely associated with pneumonia (1,2). So no antifungal therapy seems to be indicated in our patient, unless oral candidiasis (e.g. either thrush or the atrophic variety) is also simultaneously present. Time to examine the mouth!
1. El-Ebiary M, Torres A, Fabregas N, et al. Significance of the isolation of Candida species from respiratory samples in critically ill, non-neutropenic patients. Am J Resp Crit Care Med 1997;156:583-590
2. Rello J, Wsandi ME, Diaz E, et al. The role of Candida sp. isolated from bronchoscopic samples in non-neutropenic patients. Chest 1998;114:146-49
Yes! Although we often associate oral candidiasis with thrush or pseudomembranous white plaques, another common form of oral candidiasis seen in hospitalized patients is “acute atrophic candidiasis” (AAC), also referred to as “antibiotic sore mouth” because of its association with use of broad spectrum antibiotics (1,2).
Despite the absence of thrush, patients with AAC often have erythematous patches on the palate, buccal mucosa and dorsum of the tongue. Common symptoms include burning sensation in the mouth (especially with carbonated drinks in my experience), dry mouth and taste buds “being off” (2).
Aside from antibiotics, other predisposing factors for AAC include corticosteroids, HIV disease, uncontrolled diabetes mellitus, iron deficiency anemia, and vitamin B12 deficiency.
So next time you see a hospitalized patient with new onset sore, burning mouth that wasn’t present on admission, think of antibiotic sore mouth!
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1. Stoopler ET, Sollecito TP. Oral mucosal diseases. Med Clin N Am 2014;98:1323-1352. https://www.ncbi.nlm.nih.gov/pubmed/25443679
2. Millsop JW, Fazel N. Oral candidiasis. Clin Derm 2016;34:487-94. https://www.ncbi.nlm.nih.gov/pubmed/27343964