Treatment of oropharyngeal candidiasis in immunocompetent infants: a randomized multicenter study of miconazole gel vs. nystatin suspension. The Antifungals Study Group

Recent drug development and treatments for fungal infections

Fungal infections are now becoming a hazard to individuals which has paved the way for research to expand the therapeutic options available. Recent advances in drug design and compound screening have also increased the pace of the development of antifungal drugs. Although several novel potential molecules are reported, those discoveries have yet to be translated from bench to bedside. Polyenes, azoles, echinocandins, and flucytosine are among the few antifungal agents that are available for the treatment of fungal infections, but such conventional therapies show certain limitations like toxicity, drug interactions, and the development of resistance which limits the utility of existing antifungals, contributing to significant mortality and morbidity. This review article focuses on the existing therapies, the challenges associated with them, and the development of new therapies, including the ongoing and recent clinical trials, for the treatment of fungal infections. Advancements in antifungal treatment: a graphical overview of drug development, adverse effects, and future prospects.

Nystatin Effectiveness in Oral Candidiasis Treatment: A Systematic Review & Meta-Analysis of Clinical Trials

Oral candidiasis is the most common opportunistic fungal infection caused by commensal Candida species. Since there are various local and systemic predisposing factors for the disease, the treatment also varies from topical to systemic antifungal agents. Nystatin is a common antifungal agent used topically. The aim of this systematic review was to evaluate and compare the efficacy of different antifungal agents and the safety of nystatin in the treatment of oral candidiasis. Three electronic databases were searched for randomized controlled trials comparing nystatin with other anti-fungal therapies or placebo. Clinical and/or mycological cure was the outcome evaluation. A meta-analysis and descriptive study on the efficacy, treatment protocols, and safety of nystatin was also conducted. The meta-analysis included five studies, which compared the efficacy of nystatin suspensions with photodynamic therapy. A significant difference in the colony-forming units per milliliters (CFU/mL) of Candida species was observed at 60 days intervals for both palatal mucosa and denture surfaces, with both groups favoring nystatin with low heterogeneity at a 95% confidence interval. Nystatin and photodynamic therapy were found to be equally effective for the clinical remission of denture stomatitis as well as a significant reduction of CFU/mL of Candida species from dentures and palatal surfaces of the patients.

Comparison of topical antifungal agents for oral candidiasis treatment: a systematic review and meta-analysis

OBJECTIVE

To compare the efficacy and safety of topical antifungal drugs for oral candidiasis in adults and children.

STUDY DESIGN

Databases were searched from their inception to December 2020. The inclusion criterion was randomized controlled trials comparing topical antifungal agents. The primary outcomes were clinical response and mycological cure rates. The secondary outcomes were adverse reaction incidence and relapse rate.

RESULTS

In adults with oral candidiasis, fluconazole showed a better clinical response rate than clotrimazole (P = 0.001; risk ratio [RR], 1.14), but a similar mycological cure rate (P = 0.57; RR, 1.03). There was no significant difference in clinical response and mycological cure rates with either fluconazole and amphotericin B (clinical: P = 0.47, RR, 0.96; mycological: P = 0.99, RR, 1.00) or with either itraconazole and clotrimazole (clinical: P = 0.51, RR, 1.06; mycological: P = 0.45, RR, 1.32). For immunocompetent patients, fluconazole was superior to clotrimazole in terms of clinical response rate. For immunosuppressed patients, clotrimazole and itraconazole presented similar clinical response and mycological cure rates, but the relapse rate with itraconazole was lower than that with clotrimazole. In infants, miconazole and nystatin showed similar clinical response rates (P = 0.36; RR, 1.23), whereas miconazole presented a superior mycological cure rate (P = 0.03; RR, 4.03).

CONCLUSIONS

Fluconazole and amphotericin B are recommended as topical antifungal agents for adults with oral candidiasis. Existing studies tend to recommend fluconazole for immunocompetent patients and itraconazole for immunosuppressed patients, whereas miconazole is recommended for infants.

Common Child and Adolescent Cutaneous Infestations and Fungal Infections

Cutaneous infections and infestations are common among children and adolescents. Ectoparasitic infestations affect individuals across the globe. Head lice, body lice, scabies, and infestations with bed bugs are seen in individuals who reside in both resource poor areas and in developed countries. Superficial cutaneous and mucosal candida infections occur throughout the life cycle. Dermatophyte infections of keratin-containing skin and skin structures result in tinea capitis (scalp), tinea corporis (body), tinea pedis (foot), and tinea unguium (nails). Less frequent endemic fungal infections such as blastomycosis, coccidiodomycosis, and histoplasmosis may present with skin findings. This article will describe the epidemiology and transmission of these conditions as well as their clinical manifestations. The approach to diagnosis will be addressed as well as primary prevention and current therapies.

Efficacy and safety of miconazole for oral candidiasis: a systematic review and meta-analysis

The objective of this study is to assess the efficacy and safety of miconazole for treating oral candidiasis. Twelve electronic databases were searched for randomized controlled trials evaluating treatments for oral candidiasis and complemented by hand searching. The clinical and mycological outcomes, as well as adverse effects, were set as the primary outcome criteria. Seventeen trials were included in this review. Most studies were considered to have a high or moderate level of bias. Miconazole was more effective than nystatin for thrush. For HIV-infected patients, there was no significant difference in the efficacy between miconazole and other antifungals. For denture wearers, microwave therapy was significantly better than miconazole. No significant difference was found in the safety evaluation between miconazole and other treatments. The relapse rate of miconazole oral gel may be lower than that of other formulations. This systematic review and meta-analysis indicated that miconazole may be an optional choice for thrush. Microwave therapy could be an effective adjunct treatment for denture stomatitis. Miconazole oral gel may be more effective than other formulations with regard to long-term results. However, future studies that are adequately powered, large-scale, and well-designed are needed to provide higher-quality evidence for the management of oral candidiasis.

Antifungal prescribing pattern and attitude towards the treatment of oral candidiasis among dentists in Jordan

AIM

The aim of this study was to evaluate the attitude of Jordanian dentists towards the treatment of oral candidiasis and their current antifungal prescribing habits, shedding more light on the possible influence of their socio-professional factors on the pattern of prescribing and practice.

METHODS

A structured validated questionnaire was developed and tested; it was then emailed to a random sample of 600 Jordanian dental practitioners during the period of this cross-sectional survey. The questionnaire recorded practitioners' personal details and their attitude and prescribing of antifungal therapy for oral candidiasis. Statistical significance was based on probability values of <0.05 and was measured using the chi-square and Fisher's exact tests. Multiple logistic regression analysis was used to analyse the influence of respondents' socio-professional factors on their attitude towards oral candidiasis.

RESULTS

Of the 423 questionnaires returned, only 330 were included. The attitude of respondents was significantly influenced by their experience [odds ratio (OR) = 0.14; P < 0.001] and workplace (OR = 4.70; P < 0.001). Nystatin was the most commonly prescribed antifungal agent (78.2%), followed by miconazole (62.4%), which was prescribed for topical use. Systemic antifungals were prescribed by 21.2% of respondents, with a significant (P < 0.05) association with the country in which their qualification was obtained.

CONCLUSION

The attitude towards the treatment of oral candidiasis is much better among the least-experienced dentists working in private practice. Nystatin and miconazole are the most popular choices of antifungal agents among Jordanian dentists.

Preparation and evaluation of antimicrobial activity of nanosystems for the control of oral pathogens Streptococcus mutans and Candida albicans

Background

Diseases that affect the buccal cavity are a public health concern nowadays. Chlorhexidine and nystatin are the most commonly used drugs for the control of buccal affections. In the search for more effective antimicrobials, nanotechnology can be successfully used to improve the physical chemical properties of drugs whilst avoiding the undesirable side effects associated with its use. Herein described are studies using nystatin and chlorhexidine with sodium montmorillonite (MMTNa), and chlorhexidine with β-cyclodextrin and two derivatives methyl-β-cyclodextrin and hydroxypropyl-β-cyclodextrin in the development of antimicrobial nanosystems.

Methods

The nanosystems were prepared by kneading and solubilization followed by freeze-drying technique. The nanosystems were characterized by X-ray powder diffraction (XRPD), differential scanning calorimetry (DSC), and Fourier transform infrared spectroscopy (FTIR). Nanosystem antimicrobial activity against Streptococcus mutans and Candida albicans strains was evaluated with inhibition halo analysis.

Results

The nanocarriers MMTNa and cyclodextrins showed good yields. XRPD, FTIR, and DSC analysis confirmed the proposed nanosystems formation and the suitability of the production methods. The nanosystems that showed best antimicrobial effect were chlorhexidine gluconate (CHX) and cyclodextrin inclusion complexes and CHX:MMTNa 60% cation exchange capacity – 24 hours.

Conclusion

The nanosystem formulations present higher stability for all chlorhexidine inclusion complexes compared with pure chlorhexidine. The nystatin nanosystems have the potential to mask the bitter taste, justifying subsequent in-vivo studies. For these reasons, further studies are being carried out to evaluate their application in professional formulations.

Candida mastitis: a case report

Breastfeeding has been demonstrated to have many benefits for both mother and child. Nipple pain in the breastfeeding woman is a common complaint; it is the second most common cause of breastfeeding discontinuation in the first six months after childbirth. This case report addresses the characteristics of breast pain induced by Candida mastitis and the risk factors for and treatment of mastitis. Educating family physicians and other clinicians about how to recognize and treat this often difficult-to-eradicate infection will hopefully increase the percentage of mothers who breastfeed their infants through the first six months of life.

Use of antifungal agents for oral candidiasis: results of a national survey

BACKGROUND

Candida albicans is an opportunistic agent that colonizes the oral mucosa.

OBJECTIVES

To determine the attitude of Spanish dentists toward the oral treatment of candidiasis.

METHOD

Between May and November 2006, a questionnaire was circulated to a random selection of 1134 dentists obtained from the General Dental Council's main list. The survey consisted of a block of socio-demographic items followed by another block related to the diagnosis and treatment of oral candidiasis. Replies to the questionnaire were received from 840 (74%) dentists.

RESULTS

50.4% of respondents were men, and 48.1% were female with a mean age of 38 and 12.2 years of professional experience. Miconazole was the most popular choice of antifungal agent prescribed (59.3%), followed by nystatin (57.7%) for topical use. Systemic antifungal agents were used by 30.20% of dentists, with a strong association between their use and the number of years in practice, gender and professional qualifications (P < 0.005).

CONCLUSION

Most Spanish dentists make clinical diagnosis and treat oral infections by C. albicans themselves with topical drugs (miconazole and nystatin) as a first choice. Systemic treatments are more commonly chosen by male dentists with long professional experience, especially by stomatologists.

Risk Factors for Mammary Candidosis Among Lactating Women

OBJECTIVES

To document the occurrence of Candida colonization and mammary candidosis among lactating women, risk factors for Candida colonization, and the relationship between Candida colonization and breastfeeding at 9 weeks postpartum.

DESIGN

Prospective cohort study.

SETTING

Private practice clinic in Reno, Nevada.

PARTICIPANTS

100 lactating women and their infants, and 40 nonpregnant, nonlactating women (controls).

PROCEDURE

At 2 weeks postpartum, skin and milk samples were collected from the lactating women and oral samples were collected from their infants. Skin samples were collected from control subjects. All samples were cultured for Candida species. Lactating women were recontacted by phone at 9 weeks postpartum to assess infant feeding practices.

MAIN OUTCOME MEASURE

Colonization with Candida species.

RESULTS

None of the control subjects tested positive for Candida colonization. Of the lactating women, 23% tested positive for Candida and 20% had mammary candidosis. Risk factors for colonization of the mother were bottle use in the first 2 weeks postpartum and pregnancy duration of > 40 weeks. Of the 100 infants, 20% tested positive for Candida. Risk factors for colonization of the infant were bottle use in the first 2 weeks postpartum and presence of siblings. Among women who tested positive at 2 weeks, 43% were still breastfeeding at 9 weeks postpartum compared to 69% of the women who did not test positive (p < .05).

CONCLUSION

Avoidance of bottle use early postpartum may reduce the risk of mammary candidosis. Mammary candidosis is related to early termination of breastfeeding.

Mucocutaneous candidiasis

Mucocutaneous infection with Candida in neonates ranges from such common conditions as thrush and diaper dermatitis to serious diseases with potential for systemic involvement, including congenital candidiasis and invasive fungal dermatitis. In premature infants, seemingly benign mucocutaneous involvement may precede systemic infection and thus warrants thoughtful attention. Skin involvement also may be seen as an expression of systemic disease. The physical appearance of these lesions is often characteristic, allowing easy diagnosis. The patients at risk differ by gestational age and postnatal age at presentation. Systemic candidiasis and invasive fungal dermatitis typically occur in premature infants, particularly those with extremely low birth weight (< or = 1,000 g), whereas thrush and diaper dermatitis may occur in infants of any gestational age or birth weight. Congenital candidiasis presents at birth, while invasive fungal dermatitis typically occurs within the first 2 weeks of life, and thrush, diaper dermatitis, and systemic candidiasis may occur at any time in infancy. Controversy exists concerning optimal therapy of mucocutaneous candidiasis.

Candida spp. occurrence in oral cavities of breastfeeding infants and in their mothers' mouths and breasts

This study aimed to determine the occurrence of Candida spp. in the oral cavity of predominantly breastfed infants and in their mothers' mouths and breasts, as well as in the oral cavity of bottlefed infants and in non-lactating women. One hundred and sixty nine women and eighty-five milk-fed infants took part in this study and were divided into four groups: 1) infants predominantly on breastfeeding (n = 55) and their mothers (n = 55); 2) infants on bottlefeeding (n = 30); 3) non-lactating women on whom oral collections were performed (n = 80) and, 4) non-lactating women on whom breast collections were performed (n = 34). Oral and mammary swabs were cultured on Sabouraud agar dextrose with chloramphenicol. The Candida yeast strains found were isolated and identified through morphological and biochemical tests. Candida species were much less frequent in infants who were predominantly breastfed than in those who were bottlefed. Yeasts were much more frequent on the breasts of lactating women, with statistical difference in relation to the control group.

Comparison of fluconazole and nystatin oral suspensions for treatment of oral candidiasis in infants

Oral thrush is a common condition in young infants. Nystatin treatment is associated with frequent recurrences and difficulty in administration. Fluconazole was compared with nystatin for the treatment of oral candidiasis in infants. Thirty-four infants were randomized to either nystatin oral suspension four times a day for 10 days or fluconazole suspension 3 mg/kg in a single daily dose for 7 days. Clinical cures for nystatin were 6 of 19 (32%), and those for fluconazole were 15 of 15 (100%), P < 0.0001. In this small pilot study fluconazole was shown to be superior to nystatin suspension for the treatment of oral thrush in otherwise healthy infants.

Community nurses' contribution to oral health

Oral health is an important component of general health and well-being. Although oral health has improved dramatically in children and young adults, oral diseases remain common, particularly among disadvantaged and vulnerable groups. Many patients seen by community nurses will fall into these categories and are less likely to have sought treatment. This article presents the epidemiology of oral diseases and conditions for specific groups in society that community nurses will be caring for. It looks at prescribing principles and describes treatment and advice for common oral conditions, including those where prescription may be appropriate. Community nurses play an important role in the oral health care of society, particularly among those least likely to access dental services.

Mammary candidosis in lactating women

Though perceived to be a growing problem by lactation professionals, fungal infection of the breast (mammary candidosis) is largely unstudied. Candida albicans, a commensal organism encountered frequently in the vagina and gastrointestinal tract of humans, has been reported to be responsible for both superficial (cutaneous) and localized (ductal) infection of the mammary gland in lactating women, though the latter association is not universally accepted. Severe pain is considered to be characteristic of yeast infection of the breast and may be a cause of premature weaning among lactating mothers. Given that pain is often the complaint that prompts mothers to consult lactation professionals, it is important that healthcare providers working with lactating women be knowledgeable about this disease. In this article, current research regarding yeast infection of the breast is summarized, including morphology and pathology, diagnosis, risk factors, and common treatment options.