Invasive candidiasis is a severe, life-threatening infection of the bloodstream and/or deep/visceral tissues. Globally, it is thought that around 1.5 million people get the disease each year.
Candidiasis – commonly referred to as thrush – is a fungal infection from which patients typically make a full recovery. However, people with a serious illness that has weakened their immune system, such as cancer of HIV, are at risk of acquiring the invasive form of the disease.
In Ireland, a 2015 study estimated that, across the island of Ireland, around 117, 000 patients develop significant fungal disease each year. By far the most common fungal disease is recurrent Candida vaginitis, with an estimated 95, 000 cases annually. The research also estimated that around 450 cases of invasive candidiasis occur in Ireland annually.
Around 450 cases of invasive candidiasis occur in Ireland annually
Surgery is a significant risk factor for the onset of candidaemia – the form of the condition that specifically affects the bloodstream. A 2019 study found that, between 2004 and 2018, 74 patients developed candidaemia in Irish intensive care units, representing an incidence rate of 17 per 1,000 ICU admissions – significantly higher than the estimated 7.4 per 1,000 admissions previously reported in the UK.
Despite invasive candidiasis having a mortality rate of 40 per cent or more, treatments for this illness have been limited in recent years.
However, this changed earlier this year when the antifungal treatment rezafungin, trading as Rezzayo, was made available to Irish patients through the HSE’s reimbursement scheme.
This decision was supported by results from the ReSTORE Phase III clinical trial which demonstrated similar results for rezafungin, dosed once weekly, when compared to the current standard of care, caspofungin, dosed once daily.
“Invasive candidiasis continues to be one of the most serious infectious threats in critical care, associated with alarmingly high mortality rates, despite the availability of current antifungal therapies,” said Prof. Ignacio Martin-Loeches, consultant in intensive care medicine at St James’s Hospital and professor of intensive care medicine at Trinity College Dublin.
“It primarily affects the most vulnerable patients – those who are critically ill or immunocompromised – and remains difficult to treat effectively.
“Over the past 15 years, there have been few therapeutic advances, leaving clinicians with limited options in the face of this life-threatening infection. This reality underscores the urgent need for new antifungal agents.
“Invasive fungal infections consistently rank among the highest contributors to sepsis-related mortality, yet they receive disproportionately less attention in the development pipeline.
“To reverse this trend, we need meaningful collaboration between academia, clinical practice and the pharmaceutical industry, backed by sustained investment in antimicrobial innovation.
“Only through such coordinated efforts can we bring forward the next generation of antifungal treatments, that will strengthen our ability to manage severe infections in the most fragile populations.”
The rise of drug resistance is adding to the challenges clinicians face in treating both invasive and standard candidiasis.
For example, a recent HSE update on genital candidiasis cautioned that repeated single doses of the antifungal oral medication fluconazole increased the likelihood of azole resistance, and should be avoided where possible. Poor compliance with these medications – such as not using them over the full course for which they’re prescribed – is a significant factor in this resistance.
Dr Nicola Cochrane, a consultant specialising in sexual and reproductive health at the Blackrock Health Women’s Health Centre said that many clinicians are now advising more traditional topical treatments, such as pessaries and creams, as, due to rising drug resistance levels, they appear to have a better effect in treating the infection compared to oral capsules.
“We’ve looked at the potential of infection being passed between partners during sex and we know where that’s more important in some other genital infections, it’s a lot less likely to be relevant in candidiasis,” she said.
“But if someone’s having recurrent treatment – say if a woman is having recurrent vulvovaginal candidiasis and she’s in a heterosexual relationship with a male partner –then there’s some argument for her to suggest that he uses some of the cream in conjunction with her using the pessaries and cream to reduce the risk that it just flows right back up again.”
However, the use of creams by men with candidiasis poses an alternative risk. Dr Cochrane referred to recent studies suggesting that these creams can undermine the effectiveness of latex condoms increasing the risk of the spread of infections or pregnancy.
Dr Cochrane emphasises the importance of clinicians not ruling out candidiasis in women who have less typical symptoms.
“If you’re a young woman between the ages of 18 and 40, then it’s very likely that it is thrush,” she said.
“If you come in describing symptoms of skin irritation, burning, stinging, and thick, white, sticky discharge, then most doctors will be satisfied that you can make a fairly simple clinical assessment without the requirement of doing a swab, and treat with topical agents, such as pessaries and creams – that would be the first-line treatment.
“But if you have somebody who’s presenting with symptoms that are not really ticking the boxes for thrush, such as persistent itch, but no discharge, then we have to insist that people do a very thorough examination to exclude a possible skin condition as an explainer for the itch, and particularly to exclude ‘red flag’ things, because we worry that we could see things like lichen sclerosis going undiagnosed and vulva cancer. So, examination is absolutely essential.”
When a vulnerable immune-compromised patient develops invasive candidiasis, they typically present with the symptoms of severe infection
When a vulnerable immune-compromised patient develops invasive candidiasis, they typically present with the symptoms of severe infection. “They’d be feeling very, very sick so they would then go into a hospital setting with infectious diseases to oversee treatment and that is very complex,” Dr Cochrane added.
With candidiasis primarily affecting women, treating the condition will be among a range of services commonly provided in the new Blackrock Health Women’s Health Centre. The €16 million state-of-the-art facility officially opened in November at 2-5 Warrington Place, Dublin 2.
With a team of 28 consultants, four women’s medicine specialists and 30 ancillary healthcare professionals and support staff, the centre will provide access to a vast array of specialist services, all designed with the unique needs of women at their core.
The team is led by clinical director and gynaecological oncologist, Donal Brennan, who is joined by urogynaecology lead Dr Gerry Agnew, women’s medicine clinical lead Dr Caoimhe Hartley, and pain medicine specialist Prof. Kirk Levins.
Blackrock Health Women’s Health Centre will offer consultant-led clinics in gynaecology, urology, breast health, endocrinology, gastroenterology, pain medicine, cardiology, dermatology, psychology, health screening and rheumatology.
These services will be complemented by a full suite of nursing and allied health offerings, including physiotherapy, urodynamics, phlebotomy, and radiology diagnostics such as DXA scanning, mammography, and ultrasound.
“The Blackrock Health Women’s Health Centre brings together an exceptional team of specialists across a wide range of disciplines,” said Dr Hartley.
“This collaborative approach allows us to provide truly integrated care, addressing the interconnected nature of women’s health needs.”
Original source: ie