Candidiasis: Signs and Management (Pediatric Nursing)

00:00 The signs and symptoms of Candida depend on the area affected. Most yeast infections cause redness, itching, and discomfort. In immunocompetent persons, we usually see a localized infection. This involves the skin, the nails, or the mucosal membranes. In immunocompromised patients, this can move further down the esophagus and they can even develop a severe systemic infection. In infants, we commonly see thrush. Let's talk about thrush. Thrush is a creamy, white lesion on the tongue, the cheeks, the roof of the mouth, the gums, and the tonsils. This has a cottage cheese-like appearance and there's redness, burning, and pain that can even cause difficulty eating and swallowing and this can affect a nursing infant.

00:46 So, this is creamy white lesions and the clinician can go in and I have to use a tongue depressor and try to scrape this off of a baby's tongue or off of their buccal mucosa and this can leave some redness and inflammation and you can even cause slight bleeding, but this helps with the diagnosis of thrush. Next is esophageal. And this causes difficult and painful swallowing, sometimes abdominal pain, nausea, and vomiting. Now let's talk about vaginal yeast infections called vaginal candidiasis. This causes itching and this is the classic symptom.

01:17 Women will also experience burning and I always clarify if the burning is on their skin when they urinate or in their bladder and this helps me distinguish between a vaginal yeast infection and a urinary tract infection. Women will also describe soreness and irritation and on exam a whitish cottage cheese-like discharge is classic. This is the hallmark differentiator from other vaginal infections. So, how does this happen? Well, this happens when the vaginal flora gets out of whack. Normally everything including bacteria and yeast exist in a happy balance in the vagina and if one gets altered, the other is altered. So, let's say your patient is on antibiotics for an ear infection. The antibiotic is going to kill off the bacteria that's causing their ear infection, but it will also kill off the bacteria and disrupt their normal flora. And that normal flora in the vagina is what's keeping the yeast in check. They need each other.

02:11 So without the normal flora bacteria to reign in the yeast, the yeast can flourish out of control. So, I always ask patients before I start them on antibiotic therapy if they get vaginal yeast infections and if so I send in the medication and we talk about the indications and use.

02:28 Now let's cover balanitis thrush. This is red skin around the head of the penis and it causes swelling, irritation, itchiness, and soreness around the head of the penis. There can be a thick lumpy discharge under the foreskin and the clinician will have difficulty retracting the foreskin. This is called phimosis. Patients may also experience painful urination. Now let's talk about Candidal intertrigo. This is a chronic disorder that begins insidiously with the onset of itching, stinging, and a burning sensation in the skinfolds. The physical exam of the skinfolds usually shows redness and some peripheral scaling. Common sites are the inframammary folds which is the lower boundary of the breast, intergluteal cleft in the perineal region, and in the axilla which are the armpits. On exam, you look for the satellite lesions and this is where you have a central area of redness and then sort of speckles of redness splattered around.

03:25 You look for erythema and scaling and often there's a foul smelling odor. Candidal diaper rash. This is common in babies and this can occur if a contact dermatitis or a regular diaper rash is not treated within a few days because remember yeast are part of our normal flora and they can get inside. This will be a deep red color and you'll see these patches outside the diaper region. This is also noted on the creases of the thighs. So on exam, you want to do a full health history of your patient and inquire about any risk factors for yeast. You'll also examine your patient's vital signs and you want to examine the affected body system and the related body systems including the skin, mouth, throat, and of course in the diaper region.

04:10 You're going to want to perform a pelvic exam on adult patients. So, the diagnostic technique depends on the involved site. Most superficial Candidal infections can be diagnosed by performing an adequate history and physical exam. If you do need to do a test, you can do microscopy. You simply scrape or swab the area and you place it on a slide and then you drop 10% potassium hydroxide or KOH. The KOH is going to dissolve the skin cells, but it leaves the Candida intact and the pseudohyphae and buds are visualized on microscopy. You can also do a culture and this is where a sterile swab is rubbed on the skin and then cultured for several days, but this takes a while to get your results. How do we treat yeast? We use antifungal medications and the route of the medication depends on the site of infection. If your patient has oral candida or thrush, you can use topical or oral agents. If your patient has esophageal candida, you can treat orally or with IV agents. If it's a topical skin infection, you're going to use topical or oral agents and you can use topicals if they fail this treatment.

05:18 If it's a vaginal yeast infection, you can use topical or oral agents, but remember if your patient is pregnant, topicals are the only safe route. And if your patient has systemic or disseminated yeast, they're going to be treated orally or with IV agents. Now remember, repeated and chronic use of oral antifungals, these are hepatotoxic medications so you have to monitor your patient's liver function test. Complications of yeast infections are rare and patients can get secondary bacterial infections. And remember this is from the disruption and the intact skin from the yeast. We're all covered in billions of bacteria and that bacteria will get in through the break in the skin. There are some complications in pregnancy and women can also get pelvic inflammatory disease from this yeast ascending into the uterus. If there's systemic spread, the prognosis is poor and your patients will have a mortality of 30%-50%.