1. health and fitness
2. disease

Candidiasis: Overgrowth and Infection of Yeast
Event Type
Live Online
Expiration Date
7/16/2016
Credits
1 Contact Hour
Target Audience
Nurses, Pharmacists, Pharmacy Technicians
Program Overview
Candidiasis is a fungal infection that can affect areas such as the skin, genitals, throat, mouth
and blood. It’s caused by the overgrowth of a type of yeast / fungus, usually a species called
Candida albicans. This yeast is normally found in small amounts in the human body, but can
become pathogenic in certain situations. Systemic infections of the bloodstream and major
organs, particularly in immunocompromised patients, affect over 90,000 people a year in the
U.S. Candida overgrowth can cause many health problems, including fatigue, headache, poor
memory and weight gain. Many natural remedies exist to combat Candidiasis, as well as
numerous antifungal pharmaceutical agents.
Nurse Educational Objectives
 Describe the pathophysiology, frequency and implications of candidiasis
 Outline the natural/non-pharmacological methods used to treat candidiasis
 Compare and contrast the most common pharmaceuticals used to treat Candidiasis, including
mechanisms of action and potential side effects
Pharmacist Educational Objectives
 Describe the pathophysiology, frequency and implications of candidiasis
 Outline the natural/non-pharmacological methods used to treat candidiasis
 Compare and contrast the most common pharmaceuticals used to treat Candidiasis, including
mechanisms of action and potential side effects
Pharmacy Technician Educational Objectives
 List signs and symptoms of candidiasis
 List natural medicines used to treat candidiasis

List pharmaceuticals used to treat candidiasis
Activity Type
Knowledge
Accreditation
Nurse
Pharmacist
Pharmacy Technician
N-886
0798-0000-14-016-L01-P
0798-0000-14-016-L01-T
PharmCon, Inc. is accredited by the Accreditation Council for Pharmacy Education as a
provider of continuing pharmacy education.
PharmCon, Inc. has been approved as a provider of continuing education for nurses by the
Maryland Nurses Association which is accredited as an approver of continuing education in
nursing by the American Nurses Credentialing Center’s Commission on Accreditation.
Faculty
J Dufton, MD
Medical Writer & Speaker, Wellness Partners
Financial Support Received From
Pharmaceutical Education Consultants, Inc.
Disclaimer
PharmCon, Inc. does not view the existence of relationships as an implication of bias or that the
value of the material is decreased. The content of the activity was planned to be balanced and
objective. Occasionally, authors may express opinions that represent their own viewpoint.
Participants have an implied responsibility to use the newly acquired information to enhance
patient outcomes and their own professional development. The information presented in this
activity is not meant to serve as a guideline for patient or pharmacy management. Conclusions
drawn by participants should be derived from objective analysis of scientific data presented
from this activity and other unrelated sources.
Page 1
Candidiasis: Overgrowth and Infection of Yeast
© 2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Candidiasis: Overgrowth and Infection of Yeast
DISCLAIMER:
This activity contains images of an "adult" nature.
Please be sure that you do not have children within view of the computer during this activity.
DISCLAIMER:
This activity contains images of an "adult" nature. Please be sure that you do
not have children within view of the computer during this activity.
Accreditation
Faculty
Pharmacists: 0798-0000-14-016-L01-P
Pharmacy Technicians: 0798-0000-14-016-L01-T
Nurses: N-886
J Dufton, MD
Medical Writer and Speaker
Wellness Partners
CE Credit(s)
Faculty Disclosure
1 contact hour(s)
Dr. Dufton has no actual or potential conflicts of interest in
relation to this program.
Learning Objectives
•
•
•
Describe the pathophysiology, frequency and implications of Candidiasis.
Outline the natural / non-pharmacological methods used to treat Candidiasis.
Compare and contrast the most common pharmaceuticals used to treat Candidiasis, including mechanisms of action
and potential side effects.
Legal Disclaimer
The material presented here does not necessarily reflect the views of Pharmaceutical Education Consultants (PharmCon) or the companies that
support educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product discussed.
Participants should verify all information and data before treating patients or employing any therapies described in this educational activity.
Objectives
• Describe the pathophysiology, frequency and
implications of Candidiasis.
• Outline the natural / non-pharmacological methods
used to treat Candidiasis.
• Compare and contrast the most common
pharmaceuticals used to treat Candidiasis,
including mechanisms of action and potential side
effects.
Overview
•
•
•
•
•
Candida is a category of dozens of yeast / fungi species
about 20 Candida species cause infections in people
most common infectious agent = Candida albicans
infections are referred to as candidiasis
common locations of candidiasis include the intestines,
mouth, genitals and w/in moist folds of skin
• candidiasis commonly occurs in people w/ weakened
immunity or those on drug therapy:
• antibiotics and corticosteroids
• focal candidiasis can spread throughout body via the blood &
lymph and become life threatening systemic infections
Page 2
Candidiasis: Overgrowth and Infection of Yeast
© 2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Focus on C. albicans
Types of Candida
• most common cause of opportunistic fungal infections
• part of normal human flora & fauna, but can become pathogenic
and colonize skin / mucous membranes
Candida Pathogen
% of cases
Candida albicans (“monilia”)
almost 50% of all invasive candidiasis, particularly of
the vagina
Candida parapsilosis
~30%, high natural resistance to antimicrobial drugs
Candida glabrata
rising, >15%, common cause of oral thrush
Candida tropicalis
~10% of cases and is a main cause of septicemia &
disseminated candidiasis
Candida krusei
1% of cases, associated w/ infant diarrhea
Candida lusitaniae
<1% of cases, similar to C. tropicalis
Incidence / Prevalence
• a diploid fungus that grows both as a yeast
and filamentous structure (shown on right)
• lives in 80% of the human population
w/out causing harmful effects / symptoms
Unicellular
yeast
changes in
temp, pH, flora
Multi-cellular
fungal form
(or hypha)
• C. albicans can exist as 2 completely different forms
(dimorphism)
• hyphae are more virulent and can deeply penetrate tissue
• C. albicans is a true opportunistic pathogen
Incidence / Prevalence cont’d
• In the U.S., Candida species are the most common fungal infections
among the immune compromised
• Mortality rates of systemic candidiasis (candidemia) have not
improved much over the years and remain between 30-40%.
• Oropharyngeal colonization found in up to 55% of healthy young
adults, and detected in up to 65% of healthy feces.
• Systemic candidiasis causes more case fatalities than any other
systemic mycosis.
• 75% of women experience at least 1 bout of vulvovaginal
candidiasis (VVC) during their lifetimes.
• Neither sex is more predisposed to
candidiasis, but VVC is the 2nd most common cause of vaginitis.
• More than 90% of HIV patients eventually develop
oropharyngeal candidiasis (oral thrush).
• Sexually promiscuous people have significantly higher incidence.
• Neonates and adults >65 years are
most susceptible to candidiasis.
• In people w/ systemic infections, Candida species are now the 4th
most commonly isolated pathogens from blood.
• Similar rates of candidiasis / candidemia have been observed
industrialized countries, but higher rates in developing countries
Page 3
Candidiasis: Overgrowth and Infection of Yeast
© 2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Causes of Candidiasis
• Weakened Immune System: greatest risk of developing candidiasis
• compromised by diseases such as AIDS, diabetes, cancer, thyroid /
pituitary disorders, STDs
• treatment protocols such as chemotherapy & radiation
• poor nutrition, high levels of stress, chronic lack of sleep
• candidiasis spreads systemically in about 15% of cases
• Antibiotics: broad-spectrum, especially for more than a few weeks
• kills off too much of the “good” flora & fauna
• upsets balance needed for proper digestion, healthy immunity and normal
alkalinity levels
• Candida quickly takes advantage of imbalances by rapid overgrowth
• meat & dairy products, as well as municipal drinking water, can be
contaminated w/ antibiotics
• Other Pharmaceuticals: steroids, migraine meds, birth-control pills,
immunosuppressive drugs and synthetic hormone supplements
Symptoms: Oral Thrush
• Candidiasis develops anywhere in / outside the body
• Oropharyngeal candidiasis (oral thrush): infects the inside lining of
the cheeks, top and sides of tongue, throat
• light colored, cheese-like, raised lesions
that can be painful  making chewing
and swallowing difficult
• bleeding gums & sore throat common
• leads to cracking at sides of mouth
• produces sweet, musty smelling breath
• commonly occurs among kids taking
antibiotics, neonates (5-7%), people
w/ cancer (20%), AIDS patients (90%)
Causes Cont’d
• Diet: high starch diets, too much coffee, meat, alcohol, refined &
artificial sugars dramatically increase acidity (lower pH) w/in tissues,
which provides good environment for Candida to proliferate
• important nutrient deficiencies include zinc, selenium, vitamin D
• gluten sensitivity & lactose intolerance can complicate candidiasis
• Poor Hygiene: not washing well can cause
Candida to proliferate in skin folds / vagina
• complicated by obesity, reduced mobility
• Environmental factors: very significant
and often overlooked
• glues, petroleum-based solvents, silicones,
dry-cleaning chemicals, formaldehyde,
pesticides, bisphenols (plastics) and heavy
metals (lead & mercury)
Symptoms: Skin Rash
• Cutaneous candidiasis (fungal skin infection): is common in warm,
moist regions of the body, such as the underarms, buttock cleft,
underneath breasts and folds of skin.
• Obese and large breasted elderly women at higher risk,
especially if they can’t reach these areas to clean thoroughly.
• Candida skin infections are gray or reddish in color and itchy.
• often includes inflammation, blisters
and characteristic musty odor
• some diaper rashes caused by yeast
• yellow, fluid-filled spots that can
break open and become flaky
Page 4
Candidiasis: Overgrowth and Infection of Yeast
© 2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Symptoms: Nail Infection
•
•
•
•
Onychomycosis: fungal infection of toenails / fingernails
causes nail-beds to thicken, split and crumble
nail-beds turn a white, yellow or gray color
the fungal form of Candida burrows deeply into nail-beds
very difficult to eliminate
• frequently associated w/
immersion of the hands / feet in
in water and w/ diabetes
• often infects adjacent nails
• can result in nail loss
• also produces musty odor
Symptoms: Vaginal Yeast Infection
• Vulvovaginal candidiasis (VVC): often called yeast infection

• typically leads to genital itching, burning, and sometimes a clumpy
“cottage cheese-like” discharge
• soreness and inflammation common
• causes painful intercourse / urination
• not considered an STD per se, but male partners of women with
yeast infections can develop short-term rash / burning sensation
on penis
• dependent on condom use
• hyphae cause the irritation
• healthy immunity fends off infection
Symptoms: Fungal Balanitis
Pathophysiology
• Men w/ poor immunity (cancer, AIDS, diabetes) can develop
candidiasis in / around their penises  balanitis.
• Candida species are normally commensals of diseased skin and
mucosal membranes of the GI, GU and respiratory tract
• characterized by inflammation, redness, itchiness, burning pain
• intercourse / urination painful
• Candida species contain their own set of virulence factors:
• more common in uncircumcised men
• foreskin promotes accumulation of cheese-like yeast substance
• foreskins can swell and crack
• candidiasis can spread to scrotum, thighs and buttocks
• not considered an STD
• surface molecules that permit adherence to other structures
• acid proteases & phospholipases that penetrate cell envelopes
• ability to convert to a hypha form (phenotypic switching)
• Host “defects” that allow for Candida infection include:
•
•
•
•
•
poor / compromised immunity (lack of white blood cells)
disrupted flora & fauna (broad-spectrum antibiotics)
wounds, intravenous catheters, burns, ulcerations
organ / bone marrow transplants and other surgeries
severe trauma (physical / emotional), including premature birth
Page 5
Candidiasis: Overgrowth and Infection of Yeast
© 2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Pathophysiology cont’d
• First step in the development of candidiasis is colonization of
mucocutaneous surfaces. Routes of invasion include:
• disruption of skin or mucosa, allowing access to bloodstream
• deep penetration via the GI wall,
then bloodstream
• Leaky Gut Syndrome allows easy
entry of Candida into bloodstream.
• Once Candida starts to proliferate
in the blood (candidemia), systemic colonization is imminent.
• Vital organs most often affected
include brain, heart and kidneys.
Implications of Systemic Candidiasis
• about 15% of focal candidiasis becomes systemic within
patients with severely reduced immune function
• of these, between 30-40% of cases result in death from
the widespread infection of vital organs
• encephalitis (brain),
endocarditis (heart),
and nephritis (kidneys)
are most common
causes of death
Treatment Overview
Anti-Candida Diet
• Depends on severity and location, but a wide range of therapies
& doses are used to treat candidiasis.
• Candida species need poor immunity, reduced microbial
competition and a source of easily processed energy (ie. refined
sugar or alcohol) in order to thrive.
• Drug Therapies: triazoles, imidazoles, polyenes, echinocandins,
low-strength corticosteroids
• Dietary Modifications: reducing sugar intake, low dairy, less
processed foods, more alkalizing foods, no alcohol, no peanuts
• Herbal Remedies: many plant products have anti-fungal
properties such as garlic, oregano, tea tree oil, olive leaf
extract, grapefruit seeds, cloves, Echinacea, pomegranate
• Other Supplements: vitamin C, EFAs, probiotics, bee propolis
• Lifestyle Changes: wearing breathable undergarments (100%
cotton), better hygiene, more responsible use of antibiotics
• Many herbs / plants deter Candida and other types of microbes,
particularly green leafy examples such as kale, Swiss chard, bok
choy, collards, arugula, watercress and turnip greens.
• Other good veggies include hot
peppers, broccoli, celery, onions,
zucchini and Brussels sprouts.
• Citrus fruits, pomegranate and
coconuts also combat Candida.
• Fresh, raw produce almost always packs more of a medicinal
punch.
Page 6
Candidiasis: Overgrowth and Infection of Yeast
© 2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Herbal Remedies
• Raw Garlic: contains allicin -- compound proven to
kill fungi. Take 1 clove daily (or 1 tablet w/ 4,000 5,000 mcg of allicin). Increases risk of bleeding and
interacts w/ many meds.
• Coconut Oil: contains 3 different fungicidal FAs
(caprylic, capric & lauric acids) that are effective
against Candida. The FAs kill yeast by destroying cell
walls, so resistance is very unlikely. Start w/ 1-2
tablespoons each morning and increase up to 5.
• Oil of Oregano: contains carvacrol and thymol 
both fungicides that completely inhibit Candida
albicans via dehydration. Also highly effective for
prevention. Start w/ 3 drops / day diluted in water
and increase up to 6. Can cause burning sensation.
Dietary Supplements
• Vitamin C: RDA far too low
•
•
•
•
strong antioxidant able to destroy free radicals & stimulate immunity
displays anti-fungal properties and needed for tissue repair (collagen)
helps to alkalize the blood and other body fluids
dose = 1- 3 grams of vitamin C daily; too much may trigger diarrhea
• Omega-3 fats: includes ALA, EPA and DHA
•
•
•
•
strong anti-inflammatory properties and aids in tissue repair
too much omega-6 (primrose oil) cancels benefits
EPA & DHA found in fish oils; ALA in flaxseed, hemp & walnuts
may increase risk of bleeding and shouldn’t be combined w/ bloodthinners (clopidogrel, warfarin, aspirin)
• dose = 1 gram 2-4 X daily
Herbs cont’d
• Grapefruit Seed Extract: not only a strong
antifungal, but also contains vitamins C & E and
bioflavonoids such as hesperidin  all immune
boosters.10 drops diluted in water / 3x per day:
can be added to vaginal douche.
• Olive Leaf Extract: contains oleuropein, a strong
fungistatic. Also stabilizes blood sugar. Take 2
capsules (20% oleuropein) 3x daily w/ meals.
Combines well w/ vitamin C for synergistic effects.
• Goldenseal, cloves, cinnamon, sage, tea tree oil,
fresh pomegranate juice and Echinacea extracts
also have antifungal properties, but are not as
commonly used to fight Candida species.
Supplements cont’d
• Probiotics: Lactobacillus acidophilus or bifidobacterium
• helps restore normal balance of bacteria in GI & mucous membranes
• taking probiotics (“friendly bacteria”) w/ antibiotics may help prevent
buildup of Candida, although evidence is mixed
• sources include yogurt & kefir: must say “contains live / active cultures”
• at least 10 billion colony-forming units/day via supplementation
• Boric Acid / Borax: essential mineral mined from dried salt lakes
• an excellent fungicide used to treat Candida
• prevents yeast form from becoming hyphae stage
• dose = 1/8 - 1/4 teaspoon of borax powder / liter of water daily (1 wk)
• Hydrogen peroxide: controversial Candida remedy
• good general antimicrobial externally, including some fungal infections
• may promote Candida growth internally due to bactericide actions
Page 7
Candidiasis: Overgrowth and Infection of Yeast
© 2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Supplements cont’d
• Bee propolis: resinous mixture of tree sap, buds,
leaves that bees make to seal hives -- antifungal
properties noted in test tube studies. Study showed
that propolis eliminated oral thrush in people w/
denture stomatitis (mouth sores). Not appropriate
for people allergic to honey.
• Colloidal / ionic silver: one of the most powerful
and effective natural anti-fungal agents known.
Silver atoms show potent effects against Candida -comparable to amphotericin B and superior to
Diflucan. No microbe can develop resistance against
silver atoms. Main issues are particle size, purity
and cost. Learning to make it best idea. Great for
oral rinses and vaginal douches.
Topical Therapy
• Localized cutaneous candidiasis is treated with topical OTC
and Rx antifungal agents such as clotrimazole, econazole,
ciclopirox, miconazole, ketoconazole and nystatin.
• available as creams / gels / shampoos / ointments
• application for up to 4 weeks usually sufficient
• If the topical infection is deep, drainage of the abscess (if
necessary) and oral (systemic) antifungals are indicated.
• For Candida onychomycosis, oral itraconazole (Sporanox)
appears to be most effective. Two treatment regimens:
• daily dose of itraconazole (100-150mg) for 3-6 months
• pulsed-dose regimen that requires higher dose (200mg) for 7
days, followed by a 3 week break -- repeated for 3-6 months
Systemic Drug Therapy
• Fluconazole (Diflucan): agent of choice for candidemia, vaginal
candidiasis & oral thrush because it’s effective, relatively non-toxic and
the only antifungal that passes B-B barrier to treat CNS infections.
• triazoles = fungistatic (inhibit enzyme 14α-demethylase)
• some Candida species have developed resistance to fluconazole, which is
why it’s often used in combo w/ other agents
• for Candida, doses widely range from 150mg weekly to 600mg daily
• available as solution / cream / tablets
• Voriconazole (Vfend): newer triazole and used on Candida species
resistant to fluconazole; appropriate for invasive infections.
• little more toxic to the liver compared to fluconazole, but fewer side effects
compared to amphotericin B
• “salvage therapy” for infections that don’t respond to other meds
• for systemic infection, common dose = 200mg 2x daily
Systemic Therapy cont’d
• Itraconazole (Sporanox): another triazole given orally or by IV
• widely used to treat fungal nail infections
• broader spectrum of activity than fluconazole
• Posaconazole (Noxafil): a triazole given orally as a liquid
•
•
2 studies suggest it may be superior to fluconazole or itraconazole in
the prevention of invasive fungal infections, but it may cause more
serious side effects
loading dose = 300mg 2x on the first day  maintenance dose:
300mg daily for up to 2 weeks
• Imidazoles: ketoconazole (Nizoral), clotrimazole (Mycelex),
miconazole (Monistat):  in OTC shampoos / creams / lozenges
• difference between the triazoles and imidazoles involves the mechanism
of inhibition of the cytochrome P450 enzyme -- triazoles have a higher
specificity, making them more potent, but less toxic
Page 8
Candidiasis: Overgrowth and Infection of Yeast
© 2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Systemic Therapy cont’d
• Flucytosine (Ancobon): demonstrates excellent ability in killing
Candida species, although many are quick to become resistant to it.
• as such, it’s often combined w/ fluconazole and/or amphotericin-B
• recommended daily oral dose is 50-150mg / kg of bodyweight,
divided into 4 equal doses every 6 hours
• another downside is it’s very high cost -- $$$
• Amphotericin-B (many brand names): is a polyene (fungicidal) and
kills most Candida species directly, but it’s considered the most toxic
antimicrobial in clinical use -- especially to the liver
•
•
•
•
not absorbed in GI, so must be IV administered for systemic infections
often administered to patients along w/ fluconazole
initial IV infusion of 1-5mg/day, slowly increased to ~0.5mg/kg/day
also available as lipid formulations, which have been developed to
improve patient tolerability -- may show different characteristics
Topical Corticosteroids
• Topical corticosteroids (Topicort): reduce inflammation, but
also suppress the immune response.
• anti-inflammatory properties are helpful for Candida infections
of the skin, particularly in reducing itchiness and redness
• however, reduced immune response may actually promote the
spread of systemic Candida
• better suited for other skin conditions such as psoriasis
• long-term use can cause thinning of the skin and numerous other
side effects, including weight gain, hair growth and mood
problems
Systemic Therapy cont’d
• Nystatin (Mycostatin, Nilstat): also a polyene and sold primarily as
oral rinses and lozenges meant to combat oral thrush
• also available as a cream for vaginal candidiasis
• daily doses vary: 100,000 units (oral thrush) - 1 million units (systemic)
• not absorbed in the GI, so no problems w/ drug interactions
• Echinocandins: class of antifungals that include caspofungin
(Cancidas), micafungin (Mycamine) and anidulafungin (Eraxis) 
newer recommendations (2009) for use for Candida species.
•
•
•
•
glucan synthesis inhibitors: kill yeast & fungus w/out destroying cell wall
newer fungicides w/ minimal toxicity  administered via IV
caspofungin more effective, less toxic than amphotericin-B & triazoles
clinical data suggests that anidulafungin more effective in treating
severely ill systemic candidiasis patients than fluconazole
• increased rate of survival
Focus on VVC
• Acute vulvovaginal candidiasis (VVC) can be managed with either topical
antifungal agents or a single dose of oral fluconazole  150mg.
• Antifungal vaginal suppositories or creams are commonly used and effective
 duration can range from 1 day to 7 days of therapy and are usually
between 80-90% successful for an isolated acute VVC episode.
• A small percentage of women (<5%) experience chronic recurrent VVC
infections, which often require long-term oral triazole therapy.
• In such patients, the recommendation is fluconazole 150mg every other day
for 1 week, followed by weekly 150-200mg doses for 6 months  this
prevents recurrence in more than 80% of women.
• Natural douches w/ ionic silver, coconut oil, grapefruit seed extract or tea
tree oil may be effective too, but not well studied.
Page 9
Candidiasis: Overgrowth and Infection of Yeast
© 2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Candida Die-Off
• When yeast cells are rapidly killed, a die-off (Herxheimer reaction)
occurs and their metabolic by-products are released into the body
• Candida yeast cells release 79 different toxins when they die, including
ethanol and acetaldehyde
• These toxins can impair brain function and affect the endocrine, immune
& respiratory systems  often leads to “brain fog” & fatigue
• Other die-off symptoms include: nausea, headaches, dizziness, GI pain,
joint & muscle pain, chills, fever and sweating
Surgical Care
• Major organ infections associated with candidal abscesses may
require surgical drainage procedures along w/ antifungal meds.
• Prosthetic joint infection with Candida species requires the
removal of the prosthesis.
• Surgical debridement is usually necessary for joint infections,
especially vertebral osteomyelitis.
• Both pharmaceutical / natural antifungals can cause die-off symptoms
• Splenic abscesses occasionally
require splenectomy.
• The goal is to take antifungals at doses and frequencies that limit dieoff symptoms, which vary from person to person
• Heart valve replacement surgery
is always indicated to treat endocarditis caused by Candida.
• Healthy liver function is crucial in eliminating toxins from the body and
minimizing die-off symptoms
Notes:
Notes: