Candidiasis

Prevention of Exposure
(1) Candida organisms are common on mucosal surfaces and skin. No measures are available to reduce exposure to these fungi.

Prevention of Disease
(2) Data from a prospective controlled trial indicate that fluconazole can reduce the risk of mucosal (oropharyngeal, esophageal, and vaginal) candidiasis (and Cryptococcosis as well) in patients with advanced HIV disease (48) (48-50). However, routine primary prophylaxis is not recommended because of the effectiveness of therapy for acute disease, the low mortality associated with mucosal candidiasis, the potential for resistant Candida organisms to develop, the possibility of drug interactions, and the cost of prophylaxis (DIII).

Prevention of Recurrence
(3) Many experts do not recommend chronic prophylaxis of recurrent oropharyngeal or vulvovaginal candidiasis for the same reasons that they do not recommend primary prophylaxis. However, if recurrences are frequent or severe, chronic administration of an oral azole (fluconazole [CI] [48], or itraconazole solution [CI]) may be considered. Other factors that influence choices about such therapy include the impact of the recurrences on the patient's well-being and quality of life, the need for prophylaxis for other fungal infections, cost, toxicities, drug interactions, and the potential to induce resistance among Candida and other fungi. Prolonged use of systemically absorbed azoles, particularly in patients with low CD4+ T-lymphocyte counts (i.e. < 100 cells/uL), increases the risk for the development of azole resistance.

(4) Adults or adolescents who have a history of documented esophageal candidiasis, particularly multiple episodes, should be considered candidates for chronic suppressive therapy. Fluconazole at a dose of 100-200 mg daily is appropriate (BI). However, the risk of development of azole resistance should be taken into account when long-term azoles are considered.

Notes

Pediatric Notes
(5) Primary prophylaxis of candidiasis in HIV-infected infants is not indicated (DIII).

(6) Suppressive therapy with systemic azoles should be considered for infants who have severe recurrent mucocutaneous candidiasis (CIII) and particularly for those who have esophageal candidiasis (BIII).

Note Regarding Pregnancy
(7) There is limited experience with the use of antifungal drugs during human pregnancy. In addition, itraconazole is embryotoxic and teratogenic (50). Four cases of infants born with craniofacial and skeletal abnormalities following prolonged in-utero exposure to fluconazole have been reported. In addition, itraconaole is embryotoxic and teratogenic in animal systems. These same potential risks of teratogenicity are presumed to apply to other systemically-absorbed azole antifungals, such as ketoconazole. Therefore, chemoprophylaxis against oropharyngeal, esophageal, or vaginal candidiasis using systemically-absorbed azoles should not be initiated during pregnancy (DIII), and azoles should be discontinued in HIV-infected women who become pregnant (DIII). Effective birth control should be recommended to all HIV-infected women on azole therapy for candidiasis (AIII).

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