Original Title: Protocoles médicaux nationaux et ordonnances associées: traitement de première intention de la candidose buccale chez l’adulte;

Authors' objectives: The Ministère de la Santé et des Services sociaux (MSSS) gave the Institut national d’excellence en santé et en services sociaux (INESSS) the mandate to elaborate, update and host current national medical protocols and prescription templates. Pursuant to a priority ranking exercise and in the context of the implementation of the new Québec CHSLD dental care and daily hygiene program (CHSLD: residential and long-term care centers), the Direction nationale des soins et services infirmiers of the MSSS asked the INESSS to develop a national medical protocol on first-line treatment of oral candidiasis in adults residing in CHSLDs. At the first meeting with the advisory committee, it was decided to broaden the target population of the protocol and include people at risk who are not hospitalized or CHLSD residents, given the context of an ageing population and the importance of community-based and home care for that population segment.

Authors' results and conclusions: RESULTS: The information retrieval efforts identified 340 documents matching the selection criteria. Twelve (12) documents were selected for the purpose of measuring their quality. Six (6) documents were clinical practice guidelines of international health and medical organizations (such as the Infectious Diseases Society of America [IDSA], the National Institutes of Health [NIH], the World Health Organization [WHO], and the European Society of Clinical Microbiology and Infectious Diseases [ESCMID]). Five (5) others originated from clinical practice guidelines (CPG) or review journals published online by well-known professional medical associations (including the Canadian Dental Association [CDA], the Ordre des dentistes du Québec [ODQ], the Centers for Disease Control and Prevention [CDC] and MedSask); and one was a reference manual on managing oral health diseases and infections in medically compromised individuals (Dental Management of the Medically Compromised Patient, 9th Edition, Little et al., 2018). Following the evaluation of the documents with AGREE II and AACODS checklists, it was concluded to the satisfactory quality of their methodological process. From the review of clinical good practice recommendations, contextual information and experiential knowledge provided by the advisory committee members, it was possible to list clinical signs and symptoms of oral candidiasis and other mouth diseases likely to be mistaken with oral candidiasis. One of the main challenges in the treatment of oral candidiasis consists in establishing a differential diagnosis. The list will help health professionals detect clinical situations covered by the protocol and those identified as contraindicated. Furthermore, the process of elaborating the national medical protocol and collective prescription template established the best clinical practices for first-line treatment of oral candidiasis in adult patients. Although a majority of CPGs selected to elaborate this protocol recommend using fluconazole preferentially over nystatin to treat oral or oropharyngeal candidiasis, contextual information and experiential knowledge provided by the experts consulted rather support the use of nystatin in first-line treatment, on the grounds that fluconazole is more appropriate when nystatin cannot be administered safely (e.g. patients with significant cognitive disorders of dementia). Finally, some key elements of information to be communicated to the person being treated are attached to the protocol to increase the chances of successful treatment of oral candidiasis. They relate mainly to the proper use of nystatin; maintenance of good oral and prosthetic hygiene; cleaning and disinfection of dental prostheses at every treatment; rinsing of the mouth after using an inhaler containing corticosteroids; the benefits of hydration and salivation for individuals with xerostomia; and the treatment of perleche with antifungal cream or ointment. CONCLUSIONS: This national medical protocol and associated collective prescription template were elaborated on the basis of good clinical practice recommendations, which were enhanced by the experiential knowledge provided by various experts and clinicians and by contextual information. After being subjected to an analysis that required triangulating data from a number of sources, these documents should address the issues raised, limit barriers to their application, and facilitate interprofessional work. The pertinence of updating the national medical protocol will be assessed at least every four (4) years in order for the protocol to be revised within a five-year period.

Authors' methods: A systematic review of clinical practice guidelines (CPG), expert consensus, consensus conferences, guidelines and other literature containing clinical recommendations found in a number of databases was conducted in accordance with INESSS standards. Documentary research was narrowed to documents published between January 2010 and March 2019. The documents selected focused on individuals aged 18 and older from various healthcare environments (CHSLDs, home care, ambulatory care, hospitals) with symptoms and signs of oral candidiasis. Considered parameters include contraindications to pharmacological treatment, health condition assessment criteria, physical examinations, drug modalities, adverse medication effects, precautions and drug interactions that are necessary to know before initiating or adjusting pharmacological treatments, and necessary post-treatment follow-up. A manual search of literature was also conducted on the websites of North American regulatory agencies, health technology assessment agencies, government organizations, and professional associations and corporations associated with the topic under study. Bibliographies of the selected publications were consulted to identify other relevant material. The analysis of the information was carried out in a perspective of contextualization of the practice in Quebec, on the basis of legislative, regulatory and organization elements particular to Quebec, and experiential knowledge provided by the various parties consulted.

Project Status: Completed

URL for protocol: https://www.inesss.qc.ca/thematiques/medicaments/protocoles-medicaux-nationaux-et-ordonnances-associees/candidose-buccale-chez-ladulte.html#c5152

Year Published: 2020

URL for published report: https://www.inesss.qc.ca/thematiques/medicaments/protocoles-medicaux-nationaux-et-ordonnances-associees/candidose-buccale-chez-ladulte.html#c5152

Requestor: Minister of Health

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: INESSS