Mucosal Candidiasis Follow-up
- Author: Crispian Scully, MD, MRCS, PhD, MDS, CBE, FDSRCS(Eng), FDSRCPS, FFDRCSI, FDSRCSE, FRCPath, FMedSci, FHEA, FUCL, FSB, DSc, DChD, DMed(HC), Dr(HC); Chief Editor: William D James, MD more...
Patients should avoid smoking, medications that impair salivation, antibiotics, corticosteroids, and other immunosuppressants.
Antifungal azole resistance currently is a significant clinical concern, particularly in persons with HIV disease and in 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.
The prognosis is good for most infections in the immunocompetent host, but in patients who are immunocompromised, antifungal resistance is commonplace. Candidosis may predispose individuals to esophageal spread.
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