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Microbiology G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Pathology\Antibiotic Guidelines
Document Control
Title
Antibiotic Guidelines for Oropharyngeal Candidiasis in Secondary
Care
Author Author’s job title Consultant Microbiologist Antibiotic Pharmacist Directorate Diagnostics
Department Pathology Version (^) IssuedDate Status Comment / Changes / Approval 0.1 Sep 2016
Draft First draft distributed to AWG and DTC for approval
1.0 Sep 2016
Final Approved by AWG and DTC
1.1 May 2017
Revision Dosing regimen for nystatin altered by manufacturers, guideline updated to reflect this. Approved by DTC 18th May. 2 .0 Nov 2020
Final Reviewed and updated to reflect new approval process, references updated. Structure altered to fit new app layout. Submitted to IPDG for approval. Main Contact Consultant Microbiologist North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB
Tel: Direct Dial – Tel: Internal – Email:
Lead Director Director of Medicine Superseded Documents Antibiotic Guidelines for Oropharyngeal Candidiasis v1.1 20- 04 - 17 Issue Date Nov 2020
Review Date Oct 2023
Review Cycle Three years Consulted with the following stakeholders: Antibiotic Working Group Infection Prevention and Decontamination Group Consultant Gastroenterologists
Approval and Review Process Infection Prevention and Decontamination Group Clinical Audit and Guidelines Group
Local Archive Reference G:\ANTIBIOTICSTEWARDSHIP Local Path G:\ANTIBIOTIC STEWARDSHIP\Stewardship\Antibiotic policies\Published policies Filename Antibiotic Guidelines for Oropharyngeal Candidiasis v1.2 02112020 Policy categories for Trust’s internal website (Bob)
Tags for Trust’s internal website (Bob) Oral Thrush, gastrointestinal thrush
Microbiology G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Pathology\Antibiotic Guidelines
Pharmacy, Antibiotics
Microbiology G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Pathology\Antibiotic Guidelines
2.2. The author will be responsible for ensuring the guidelines are reviewed and revisions approved by the Infection Prevention and Decontamination Group in accordance with the Document Control Report.
2.3. All versions of these guidelines will be archived in electronic format by the author within the Antibiotic Stewardship policy archive.
2.4. Any revisions to the final document will be recorded on the Document Control Report.
2.5. To obtain a copy of the archived guidelines, contact should be made with the author.
2.6. Monitoring of implementation, effectiveness and compliance with these guidelines will be the responsibility of the Lead Clinician for Antibiotic Stewardship. Where non-compliance is found, the reasons for this must have been documented in the patient’s medical notes.
Role of Antibiotic Working Group (AWG)
2.7. The AWG is responsible for:
Leading antibiotic guideline development and review within Northern Devon Healthcare Trust Involving all relevant stakeholders in guideline development and review
3. Contacts
Contact numbers:
Microbiologist Bleep 193. Via switchboard out of hours. Antibiotic Pharmacist Bleep 029 (Mon-Fri only)
4. Management of Oropharyngeal Candidiasis
See appendix 1
5. Monitoring Compliance with and the Effectiveness of the
Guideline
Suggested audit criteria
5.1. The following could be used:
100% patients taking medication which interacts with miconazole are prescribed nystatin 100% patients are prescribed the appropriate volume(s) of antifungal treatment
Microbiology G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Pathology\Antibiotic Guidelines
Process for Implementation and Monitoring Compliance and
Effectiveness
5.2. Incidents involving gastroenterological infection should be reported according to the Trust’s Incident Reporting Policy. Critical incident reports relating to gastroenterological infection will be collated by the Antibiotic Pharmacist. Results will be reported on an annual basis to the Infection Prevention and Decontamination Group.
6. Equality Impact Assessment
6.1. The author must include the Equality Impact Assessment Table and identify whether the policy has a positive or negative impact on any of the groups listed. The Author must make comment on how the policy makes this impact.
Table 1: Equality impact Assessment
Group Positive Impact^ Negative Impact Impact^ No Comment Age X Disability X Gender X Gender Reassignment X Human Rights (rights to privacy, dignity, liberty and non-degrading treatment)
X
Marriage and civil partnership
X
Pregnancy X Advice contained within guideline. Maternity and Breastfeeding
X Advice contained within guideline. Race (ethnic origin) X Religion (or belief) X Sexual Orientation X
7. References
7.1. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press http://www.new.medicinescomplete.com [Accessed on 02/11/2020]
7.2. Paediatric Formulary Committee. BNF for Children (online) London: BMJ Group, Pharmaceutical Press, and RCPCH Publications http://www.new.medicinescomplete.com [Accessed on 02/11/2020]
Microbiology G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Pathology\Antibiotic Guidelines
Acute superficial Candidiasis infection is typically triggered by a disturbance in the normal oral flora. Identify and, if possible, eliminate or manage any precipitating factors for candidiasis alongside prescribing treatment for the infection. Acute infections should normally resolve with good oral hygiene and topical treatment.
Oral Thrush (pseudomembranous oral candidiasis): Curd-like, white or yellowish plaques anywhere in the mouth, especially cheeks, gums, palate, and tongue. Underlying redness, not usually painful. Minimal symptoms in acute infection (burning and itching sensation) Chronic forms may involve the oesophageal mucosa, leading to dysphagia and chest pains. Neonates, elderly people, immunocompromised, taking broad spectrum antibiotics, and people with xerostomia.
Acute atrophic oral candidiasis (acute erythematous oral candidiasis) Marked soreness and erythema, particularly on the palate and dorsum of the tongue. Filiform papillae disappear, dorsal surface of the tongue appears smooth. Asymptomatic or mild burning and itching sensation Seen in immune depressed and immunocompetent people, common after treatment with oral antibiotics. Denture stomatitis (chronic erythematous candidiasis or chronic atrophic oral candidiasis) Redness, and rarely soreness, in the denture-bearing area. 50 – 70% of denture wearers affected. Angular cheilitis Redness, fissuring, soreness at the corners of the mouth. Bacterial infection (mainly Staphylococcus aureus ) as well as yeast ( Candida ) species. Older people (particularly reduced facial height or ill-fitting dentures), younger immunocompromised people, anaemia or vitamin B12 deficiency. Chronic plaque-like oral candidiasis (chronic hyperplastic candidiasis) Nodular form or white plaques on the cheek or tongue, not easily removed. Candida hyphae invade deeper levels where epithelial dysplasia can be observed. Mild symptoms, associated with malignancy. Men older than 30 years of age and in smokers.
Microbiology G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Pathology\Antibiotic Guidelines
Median rhomboid glossitis Central, red, demarcated area of papillary atrophy of the tongue (from the posterior midline just anterior to the circumvallate papillae) Rarer – 1% population. Males, smokers, people using corticosteroid inhalers, and people with diabetes. It can lead to recurrent or chronic atrophic candidal infection. Oesophageal candidiasis Usually diagnosed at endoscopy when white mucosal plaque-like lesions are noted. Confirmatory biopsy shows the presence of yeasts and pseudohyphae invading mucosal cells, and culture reveals Candida Candida is part of the normal oral flora, so culturing it from swabs is rarely helpful. In cases failing to respond to empirical treatment, culture may be used to support the diagnosis, and look for unusual and/or azole-resistant Candida species. Biopsy should be considered in patients with “intractable, culture negative” oral thrush.
9.4. Things To Watch Out For (Red Flags)
Timeline months-years of sore mouth, change in character of chronic candidiasis lesions, or different colour lesions appearing recently. These patients may also warrant referral to maxillofacial or dermatology. Persistent swallowing difficulties after oropharyngeal thrush treatment, particularly in patients with history of smoking or other risk factors for oral cancer. Referral to ENT, and gastroenterology for endoscopy. Patients whose oral problems are causing decrease in oral intake, or concerns about nutrition. Referral to gastroenterology or maxillofacial
Onward referral required for investigation - discuss with specialists whether acute Candida treatment is also indicated in each case.
9.5. Drug Treatment. [open]
Mild Acute Infection
Acute infections should normally resolve with good oral hygiene and topical treatment. Pay attention to risk factors (see non-pharmacological measures)
First-Line
Nystatin Oral Suspension 100,000 units/mL
NB: Not absorbed systemically, can be used alongside systemic treatment for fungal infection if required. Avoid contact with eyes and other mucous membranes.
All paediatric and adult patients: 1mL QDS PO
Microbiology G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Pathology\Antibiotic Guidelines
Neonate 0-13 days: 3-6 mg/kg on day 1, then give 3mg/kg every 72 hours thereafter
Neonate 14-28 days: 3-6mg/kg on day 1, then give 3mg/kg every 48 hours thereafter
Child 1 month – 11 years: 3-6mg/kg on day 1, then give 3mg/kg OD for 7- days (max. 14 days except in severely immunocompromised patients)
Child 12 years and over, and Adult: 50mg OD for 7-14 days (max. 14 days except in severely immunocompromised patients).
Oesophagitis
Neonates 0-28 days: See Oropharyngeal candidiasis treatment guideline
Child 1 month – 11 years: 3-6mg/kg on day 1, then give 3mg/kg OD for 14- days
Child 12 years and over, and Adult: 50mg OD for 14-30 days, dose may be increased to 100mg OD for unusually difficult infections
9.6. Non-Pharmacological Measures [closed]
Managing risk factors for developing oral candidiasis:
Wearing dentures or orthodontic braces with plates: good oral hygiene and thorough washing of teeth/brace to eliminate source of infection. Advise patient to sleep without teeth/brace if possible. Allowing teeth/brace to air dry after disinfection also kills adherent Candida. Miconazole gel may be applied to the underside of the plate if patient is unable to go without wearing teeth/brace at any time. Note cautions and interactions for miconazole before prescribing it.
Smoking – Encourage patients to think about stopping, offer smoking cessation products if needed.
Antibacterial therapy – Assess continuing need for antibacterial therapy and stop if appropriate.
Corticosteroid use (particularly inhaled) – Encourage patient to use their steroid inhaler before brushing teeth twice daily. This will help to remove leftover traces of corticosteroid powder from oral cavity. Using mouthwash may also help to remove particles from mucosa.
Microbiology G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Pathology\Antibiotic Guidelines
Hyposalivation (e.g. due to medications such as antipsychotics, or radiotherapy for oral cancer) – Advise patient to rinse around mouth with sips of water regularly and encourage good oral hygiene. Consider mouthwashes or artificial saliva if patient unable to comply with lower- impact lifestyle advice. If other side-effects of psychotropic medications are also problematic, consider seeking advice from liaison psychiatry regarding medication review. Note that rinsing mouth should not be attempted for at least an hour after administration of topical antifungal treatment.
Diabetes – thrush may be associated with poor glycaemic control.
Cytotoxic or immunosuppressive medication – Patients may require treatment at certain points during cancer chemotherapy cycles for the length of their cytotoxic treatment. For patients on permanent immunosuppression, managing other risk factors and concentrating on maintaining good oral hygiene to prevent infection is preferred. Treat as needed when acute infection occurs.
Always consider reasons for immunosuppression in patients with oesophageal candida (particularly HIV and haematological malignancy).
Teething aids/chewable toys – Ensure these have been thoroughly cleaned to reduce risk of reinfection.
9.7. If No Better [closed]
Nystatin suspension relies on long contact time with the affected mucosa. Ensure the patient has been instructed on how to use it properly before changing to a different treatment.
If patient has been using their medication as prescribed, consider sending swabs for MC&S as sometimes different organisms can be responsible for infection. This is particularly relevant for patients with immune suppression due to underlying disease or medications.
9.8. Version control [closed]
Antibiotic Guidelines for Oropharyngeal Candidiasis v1.2 02112020
