Candidiasis, Mucosal Follow-up
- Author: Crispian Scully, MD, PhD, CBE, MDS, MRCS, FDSRCS, FDSRCPS, FFDRCSI, FDSRCSE, FRCPath, FMedSci, FHEA, FUCL, DSc, DChD, DMed(HC), Dr (HC) ; Chief Editor: Dirk M Elston, MD more...
Deterrence/Prevention
Patients should avoid smoking, xerostomic medication, antibiotics, corticosteroids, and immunosuppressants.
Complications
Antifungal azole resistance currently is well recognized and is becoming a significant clinical concern, particularly in persons with HIV infection and other immunocompromised conditions. Azole resistance appears to arise because of changes in the target enzyme 14-alpha sterol demethylase, reduced fungal membrane permeability to azoles, changes in delta-5 and delta-6 desaturase, or increased efflux of azoles from the organisms.
Ketoconazole resistance has been reported, but is not a concern, since fluconazole is active against at least some ketoconazole-resistant Candida species.
Emergence of resistance during fluconazole therapy currently is a true clinical concern, especially in persons who use illegal intravenous drugs. The commercially available E test is a simple reliable test useful in detecting fluconazole-resistant C albicans.
- Fluconazole resistance appears to result from a mutation and may appear in patients who have received no fluconazole, since resistance may be transferred, possibly through sexual transmission.
- Previous fluconazole use and severe immune defects are risk factors for fluconazole resistance.
- Intermittent fluconazole or low-dose therapy is more likely than continuous or high-dose therapy to induce resistant species.
- One US study found that at least 1 fungal species resistant to fluconazole was isolated from 41% of patients with AIDS; other studies found that as many as 20% of patients had fluconazole-resistant oral candidosis.
- Some evidence exists of cross-resistance of some C albicans and non-C albicans isolates to ketoconazole, fluconazole, and itraconazole, although the clinical significance of this in HIV disease remains to be established.
- Some studies indicate that ketoconazole and itraconazole may be clinically effective, despite some cross-resistance.
- Itraconazole in particular may remain effective, although clinical efficacy may be impaired. Approximately 30% of fluconazole-resistant isolates may be resistant to itraconazole. Itraconazole also is effective as a cyclodextrin solution in patients with fluconazole-resistant candidosis.
- Therapy in fluconazole-resistant cases includes topical amphotericin, higher oral doses of fluconazole (200-600 mg/d), a fluconazole suspension as an oral rinse, or the use of ketoconazole (400 mg/d) or itraconazole (200-400 mg/d).
- Oral, intravenous, or liposomal amphotericin also may be effective, and, although resistance to oral amphotericin eventually arises, intravenous amphotericin appears to remain effective.
Prognosis
The prognosis is good for most infections in the immunocompetent host, but in patients who are immunocompromised, antifungal resistance is commonplace.
Patient Education
For excellent patient education resources, visit eMedicine's Yeast and Fungal Infections Center. Also, see eMedicine's patient education article Candidiasis (Yeast Infection).
Boriollo MF, Bassi RC, dos Santos Nascimento CM, Feliciano LM, Francisco SB, Barros LM. Distribution and hydrolytic enzyme characteristics of Candida albicans strains isolated from diabetic patients and their non-diabetic consorts. Oral Microbiol Immunol. Dec 2009;24(6):437-50. [Medline].
Redding SW, Dahiya MC, Kirkpatrick WR, et al. Candida glabrata is an emerging cause of oropharyngeal candidiasis in patients receiving radiation for head and neck cancer. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Jan 2004;97(1):47-52. [Medline].
Lafleur MD, Qi Q, Lewis K. Patients with long-term oral carriage harbor high-persister mutants of Candida albicans. Antimicrob Agents Chemother. Jan 2010;54(1):39-44. [Medline].
Sitheeque MA, Samaranayake LP. Chronic hyperplastic candidosis/candidiasis (candidal leukoplakia). Crit Rev Oral Biol Med. 2003;14(4):253-67. [Medline].
Golecka M, Oldakowska-Jedynak U, Mierzwinska-Nastalska E, Adamczyk-Sosinska E. Candida-associated denture stomatitis in patients after immunosuppression therapy. Transplant Proc. Jan-Feb 2006;38(1):155-6. [Medline].
Tanida T, Okamoto T, Okamoto A, et al. Decreased excretion of antimicrobial proteins and peptides in saliva of patients with oral candidiasis. J Oral Pathol Med. Nov 2003;32(10):586-94. [Medline].
Niimi M, Firth NA, Cannon RD. Antifungal drug resistance of oral fungi. Odontology. Feb 2010;98(1):15-25.
Scardina GA, Ruggieri A, Messina P. Chronic hyperplastic candidosis: a pilot study of the efficacy of 0.18% isotretinoin. J Oral Sci. Sep 2009;51(3):407-10. [Medline].
Fanello S, Bouchara JP, Sauteron M, et al. Predictive value of oral colonization by Candida yeasts for the onset of a nosocomial infection in elderly hospitalized patients. J Med Microbiol. Feb 2006;55:223-8. [Medline].
Lynch DP. Oral candidiasis. History, classification, and clinical presentation. Oral Surg Oral Med Oral Pathol. Aug 1994;78(2):189-93. [Medline].
Rautemaa R, Hietanen J, Niissalo S, Pirinen S, Perheentupa J. Oral and oesophageal squamous cell carcinoma--a complication or component of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED, APS-I). Oral Oncol. Jul 2007;43(6):607-13. [Medline].
Scully C, el-Kabir M, Samaranayake LP. Candida and oral candidosis: a review. Crit Rev Oral Biol Med. 1994;5(2):125-57. [Medline].
Taillandier J, Esnault Y, Alemanni M. A comparison of fluconazole oral suspension and amphotericin B oral suspension in older patients with oropharyngeal candidosis. Multicentre Study Group. Age Ageing. Mar 2000;29(2):117-23. [Medline].
Print
