CANDIDA SPECIES

February 5, 2018
 I. Morphology, Structure, and
Physiology of the Organism
II. Determinants of
Pathogenicity
OUTLINE III. Epidemiology/ Transmission
IV. Laboratory Diagnosis
V. Diseases in
Women/Pregnant Women
VI. Treatment/ Prevention
I. Morphology,
Structure, and
Physiology of the
Organism
 Candida is a unicellular yeast
fungus
  KINGDOM: Fungi
 PHYLUM: Ascomycota
 SUBPHYLUM: Ascomycotina
CANDIDA  CLASS: Ascomycetes
 ORDER: Saccharomycetales
 FAMILY: Saccharomycetaceae
 GENUS: Candida
There are many species of
Candida (>160)
The common species are:
Candida albicans,
C.parapsilosis
C.tropicalis,
C.glabrata,
C.krusei,
 Oval-shaped diploid fungus
 Thick cell wall of mannan and
glucan polysaccharides
 Unicellular, budding (asexual)
reproduction (blastospores)
 Filament formation
 Pseudohyphae (buds stay
attached, constricted, chains of
elongated blastospores)
 Hyphae (buds germinate)
 The organism is dimorphic and changes
from one morphological form to the next in
different environmental conditions.
 Normal room temperatures or even
anaerobic conditions favour the yeast form
of the organism, which reproduce by
budding and are typically 10 to 12 µm
(micrometres) in diameter, but under
physiological conditions (body temperature,
pH, and the presence of serum) it may
develop into a hyphal form called
pseudohyphae.
 The transition from a commensal to a
pathogenic lifestyle involves changes in
environmental conditions and dispersion
within the human host.
II. Determinants of
Pathogenicity
Filamentation-
escape macrophages
Hwp1- adhesion
Slr1- hyphal formation
Candidalysin-
contributes to
virulence
III. Epidemiology/
Transmission
  4th most common cause of
nosocomial blood stream
infection (US)
 Leading cause of invasive fungal
infection in critically ill adult and
neonatal patients cared for in
EPIDEMIOLOGY intensive care units (ICU)
 Second cause of invasive fungal
infection in severely
immunocompromised patients
 One of the top causes of fungal
infections in the Philippines
Human commensal (endogenous)
 skin, gastrointestinal,
genitourinary tracts
 5 - 15% carriage rate in normal
people
 increased carriage with use of
antibiotics
Environmental (exogenous)
 much less common
 food, animals, soil hospital
environment
  Alteration in
 Immunity
 Normal physiology
Opportunistic  Normal flora
Fungal  Damage in the barriers
Infection

 Clinical – Spectrum of disease

  Colonization precedes
Transmission infection
of  Antibiotic suppression of
Opportunistic normal flora, fungal
Fungi overgrowth
  A primary or secondary mycotic
infection caused by members of
CANDIDIASIS the genus Candida.
  Mucous membrane infections
 Thrush (oropharyngeal)
 Esophagitis
 Vaginitis

CANDIDIASIS  Cutaneous infections

 Paronychia (skin around nail bed)
 Onychomycosis (nails)
 Diaper rash
 Chronic mucotaneous candidiasis
 children with T-cell abnormality
IV. Laboratory
Diagnosis
Candidiasis – Laboratory diagnosis
Specimen depend on site of infection.
Swabs, Urine, Blood, Respiratory specimens, CSF,
Blood
1. Direct microscopy :
Gram stain, KOH, Giemsa, GMS, or PAS stained
smears.
Budding yeast cells and pseudohyphae will be seen
in stained smear or KOH.
Candidiasis – Laboratory diagnosis
2. Culture:
Media: SDA & Blood agar at 37oC,
Creamy moist colonies in 24 - 48 hours.

3. Blood culture
 Candidiasis – Laboratory diagnosis
Laboratory identification of Yeast

Because C. albicans is the most common species to cause infection

 The following tests are used to identify C. albicans:
1. Germ tube test : Formation of germ tube when cultured in
serum at 37ᵒC
2. Chlamydospore production in corn meal Agar
3. Resistance to 500 μg/ml Cycloheximide Germ tube test

 If these 3 are positive this yeast is C.albicans,

 If negative, then it could be any other yeast,
 Use Carbohydrate assimilations and fermentation.
Commercial kits available for this like: API 20C, API 32C
Chlamydospores of
 Culture on Chromogenic Media (CHROMagar™ Candida) C. albicans in CMA
 Candida species
Candida albicans
Sabouraud Agar
Morphology: Creamy white yeast,
may be dull, dry irregular and
heaped up, glabrous and tough

Chromagar
producing green pigmented colonies
on specially designed medium to
speciate certain yeasts based on
color they produce
 Candida species
Germ tube: inoculation of yeast in horse
serum incubated at 370C for 2 to 3 hours

Germ Tube: Positive

Germ tube is a continuous filament
germinating from the yeast cell without
constriction at the point of attachment.
e.g. C. albicans, C. dubliniensis

Germ Tube: Negative

Shows constriction at the attachment site
e.g. other Candida species, esp. C. tropicalis
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 Candida species

Candida albicans
Oxgall Agar
large round and thick
walled chlamydospores
x400 x1000
Cornmeal Agar
clusters of blastospores along x400
pseudohyphae at regular
x1000
intervals
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Yeast
Identification

Carbohydrates assimilation test , API 20C

 4. Serology:

Patient serum
Candidiasis Test for Antigen , e.g.
Mannan antigen using ELISA
– Laboratory Test for Antibodies
diagnosis

5. PCR
V. Diseases in
Women/ Pregnant
Women
Vulvovaginal
Candidiasis (VVC)
Clinical Presentation and Symptoms

• Vulvar pruritis is most common symptom.

• Thick, white, curdy vaginal discharge
("cottage cheese-like")
• Erythema, irritation, occasional
erythematous "satellite" lesion
• External dysuria and dyspareunia
Vulvovaginal Candidiasis
 Diagnosis
• History, signs and symptoms
• Visualization of pseudohyphae (mycelia)
and/or budding yeast (conidia) on KOH or
saline wet prep
• pH normal (4.0 to 4.5)
– If pH > 4.5, consider concurrent BV or
trichomoniasis infection
• Cultures not useful for routine diagnosis
 Candidiasis Curriculum Diagnosis

PMNs and Yeast Pseudohyphae

Saline: 40X objective Yeast

pseudohyphae

Yeast
buds
PMNs

Squamous epithelial cells

41
Source: Seattle STD/HIV Prevention Training Center at the University of Washington
 Candidiasis Curriculum Diagnosis

Yeast Pseudohyphae
Lysed
10% KOH: 10X objective
squamous
Masses of yeast epithelial cell
pseudohyphae

42
Seattle STD/HIV Prevention Training Center at the University of Washington
 Candidiasis Curriculum Diagnosis

PMNs and Yeast Buds

Saline: 40X objective

Folded squamous
epithelial cells

Yeast
buds
PMNs

43
Seattle STD/HIV Prevention Training Center at the University of Washington
Candidiasis Curriculum Management

Uncomplicated VVC

• Mild to moderate signs and symptoms

• Nonrecurrent
• 75% of women have at least one
episode
• Responds to short course regimen

44
 Candidiasis Curriculum Management
CDC-Recommended Treatment Regimens for
Uncomplicated VVC
Over-the-Counter Intravaginal Agents
– Butoconazole 2% cream, 5 g intravaginally for 3 days or
– Clotrimazole 1% cream 5 g intravaginally for 7-14 days or
– Clotrimazole 2% cream 5 g intravaginally for 3 days or
– Miconazole 2% cream 5 g intravaginally for 7 days or
– Miconazole 4% cream 5 g intravaginally for 3 days or
– Miconazole 100 mg vaginal suppository, 1 suppository for 7 days or
– Miconazole 200 mg vaginal suppository, 1 suppository for 3 days or
– Miconazole 1,200 mg vaginal suppository, one suppository for 1 day or
– Tioconazole 6.5% ointment 5 g intravaginally in a single application

Prescription Intravaginal Agents

– Butoconazole 2% cream, 5 g (single dose bioadhesive product) intravaginally for 1 day or
– Nystatin 100,000-unit vaginal tablet, 1 tablet for 14 days or
– Terconazole 0.4% cream 5 g intravaginally for 7 days or
– Terconazole 0.8% cream 5 g intravaginally for 3 days or
– Terconazole 80 mg vaginal suppository, 1 suppository for 3 days

Prescription Oral Agents

– Fluconazole 150 mg oral tablet, 1 tablet in a single dose
Note: The creams and suppositories in these regimens are oil-based and may weaken latex condoms and
diaphragms. Refer to condom product labeling for further information. 45
Candidiasis Curriculum Management

Complicated VVC
• Recurrent (RVVC)
– Four or more episodes in one year
• Severe
– Edema
– Excoriation/fissure formation
• Non-albicans candidiasis
• Compromised host

46
Candidiasis Curriculum Management

Complicated VVC Treatment

• Recurrent VVC (RVVC)
– 7–14 days of topical therapy, or
– 100 mg, 150 mg , or 200 mg oral dose of
fluconozole repeated every 3 days (days
1,4,and 7)
– Maintenance regimens (see 2010 CDC STD
treatment guidelines)

• Severe VVC
– 7–14 days of topical therapy, or
– 150 mg oral dose of fluconozole repeated in
72 hours 47
Candidiasis Curriculum Management

Complicated VVC Treatment

(continued)
• Non-albicans
– Optimal treatment unknown
– 7–14 days non-fluconazole therapy
– 600 mg boric acid in gelatin capsule vaginally
once a day for 14 days for recurrences
• Compromised host
– 7–14 days of topical therapy
• Pregnancy
– Fluconazole is contraindicated
– 7-day topical agents are recommended
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Candidiasis Curriculum

Lesson VI: Prevention

49
Candidiasis Curriculum Prevention

Partner Management
• VVC is not usually acquired through sexual
intercourse.
• Treatment of sex partners is not
recommended.
• A minority of male sex partners may have
balanitis and may benefit from treatment with
topical antifungal agents to relieve symptoms.

50
Candidiasis Curriculum Prevention

Patient Counseling and

Education
• Nature of the disease
– Normal vs. abnormal vaginal discharge,
signs and symptoms of candidiasis, maintain
normal vaginal flora
• Transmission Issues
– Not sexually transmitted
• Risk reduction
– Avoid douching, avoid unnecessary antibiotic
use, complete course of treatment

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VI. Treatment
  Oropharyngeal:
 Topical Nystatin suspension,
Clotrimazole troches ,Miconazole,
Fluconazole suspension.
Candidiasis-
Treatment  Systemic treatment of Candidiasis
Fluconazole
Voriconazole
Caspofungin
Amphotericin