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Esophageal involvement is the most frequent type of significant mucosal disease Presenting symptoms include substernal odynophagia, gastroesophageal reflux, or nausea without substernal pain Oral candidiasis, though often associated, is not invariably present Diagnosis is best confirmed by endoscopy with biopsy and culture Therapy depends on the severity of disease If patients are able to swallow and take adequate amounts of fluid orally, fluconazole, 100 mg/d (or itraconazole solution, 10 mg/mL, 100 mg/d), for 10 14 days will usually suffice In the individual who is more ill or in whom esophagitis has developed while taking fluconazole, options include oral or intravenous voriconazole, 200 mg twice daily; intravenous amphotericin B, 03 mg/kg/d; or intravenous caspofungin, 50 mg/d; or intravenous micafungin, 150 mg/d Relapse is common with all agents when there is underlying HIV infection without adequate immune reconstitution Vulvovaginal candidiasis occurs in an estimated 75% of women during their lifetime Risk factors include pregnancy, uncontrolled diabetes mellitus, broad-spectrum antimicrobial treatment, corticosteroid use, and HIV infection Symptoms include acute vulvar pruritus, burning vaginal discharge, and dyspareunia Various topical azole preparations (eg, clotrimazole, 100 mg vaginal tablet for 7 days, or miconazole, 200 mg vaginal suppository for 3 days) are effective One 150 mg oral dose of fluconazole has been shown to have equivalent efficacy with better patient acceptance Disease recurrence is common but can be decreased with weekly fluconazole therapy (150 mg weekly)

You can now set the controls of the credit management to the combination of credit control area plus customers risk category plus credit group, as seen in Figure 10-7 You can see in the previous example that we have automatic settings for a high-risk customer for a sales order, while a medium-risk customer and a low-risk customer are only checked in a delivery This is only an example and in some instances you may find it necessary to check all customers at the time of the sales order After you have assigned the credit control area and the credit group, you need to assign the risk category in the customer master record

Common normal flora but opportunistic pathogen Gastrointestinal mucosal disease, particularly esophagitis, most common Catheter-associated fungemia occurs in patients who have sustained mucosal injury or received broadspectrum antibiotics

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Candida albicans can be cultured from the mouth, vagina, and feces of most people Cutaneous and oral lesions are discussed in s 6 and 8, respectively The risk factors for invasive candidiasis include prolonged neutropenia, recent abdominal surgery, broad-spectrum antibiotic therapy, renal failure, the presence of intravascular catheters (especially when providing total parenteral nutrition), and injection drug use Cellular immunodeficiency predisposes to mucocutaneous disease

Candidal funguria frequently resolves with discontinuance of antibiotics or removal of bladder catheters Clinical benefit from treatment of asymptomatic candiduria has not been demonstrated, but persistent funguria should raise the suspicion of disseminated infection When symptomatic funguria persists, oral fluconazole, 200 mg/d for 7 14 days, can

be used if renal function is normal Rare complications of candidal urinary tract infections are ureteral obstruction and dissemination

.

The diagnosis of disseminated Candida infection is problematic because Candida species are often isolated from mucosal sites in the absence of invasive disease while blood cultures are positive only 50% of the time in disseminated infection Serologic tests have not proved useful for distinguishing colonization from invasive disease Thus, the decision to treat for Candida when organisms are isolated from urine or sputum (or both) needs to be individualized for each patient Disseminated candidiasis may represent a benign, self-limited process, but until proven otherwise it should be considered a sign of serious, complicated disease If fungemia resolves with removal of intravascular catheters, there are often no further complications, but the incidence of endophthalmitis may be higher than previously recognized Other organ system involvement in invasive disease may include the skin, brain, meninges, and myocardium Antifungal therapy for invasive candidiasis is rapidly evolving with the addition of new agents and the emergence of non-albicans species causing significant disease Options for treatment include fluconazole, 400 800 mg daily; amphotericin B, 03 05 mg/kg/d; voriconazole, 200 mg twice a day; caspofungin, 50 mg/d; or micafungin, 100 mg daily Combination therapy with azoles and amphotericin B is an area being explored Flucytosine, 150 mg/kg/d orally in four divided doses, is added if central nervous system involvement occurs Therapy for disseminated candidiasis should be continued for 2 weeks after the last positive blood culture and resolution of symptoms and signs of infection Once patients have become clinically stable, parenteral therapy can be discontinued and oral fluconazole, 200 800 mg orally given as one or two doses daily, is used to complete treatment Although debated, removal or exchange of intravascular catheters is generally recommended and substantially decreases the duration of candidemia and overall mortality, which approaches 30% Another form of invasive disease is hepatosplenic candidiasis This results from aggressive chemotherapy and prolonged neutropenia in patients with underlying hematologic cancers Typically, fever and variable abdominal pain present weeks after chemotherapy, when neutrophil counts have recovered Blood cultures are generally negative Hepatic enzymes reveal an alkaline phosphatase elevation that may be marked Fluconazole, 400 mg daily, or a lipid formulation of amphotericin B is given until clinical and radiographic improvement occurs.

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