Candidiasis Flashcards
What is the most common cause of oropharyngeal and esophageal candidiasis in people with HIV?
Candida albicans
Non–C. albicans species have been increasingly reported due to increased selection pressure from azole use.
At what CD4 T lymphocyte cell count is oropharyngeal or esophageal candidiasis typically observed?
<200 cells/mm3
Esophageal disease typically occurs at lower CD4 counts than oropharyngeal disease.
What are the characteristic lesions of oropharyngeal candidiasis?
Painless, creamy white, plaque-like lesions
Lesions can be scraped off with a tongue depressor.
How does esophageal candidiasis generally present?
Retrosternal burning pain or discomfort and odynophagia
Occasionally, esophageal candidiasis can be asymptomatic.
What is the preferred therapy for initial episodes of oropharyngeal candidiasis?
Fluconazole 200-mg loading dose, followed by 100–200 mg PO once daily (AI)
Duration of therapy is 7–14 days.
What is the duration of therapy for esophageal candidiasis?
14–21 days
Systemic antifungals are required for effective treatment.
What should be suspected in people with low CD4 count presenting with substernal chest pain and odynophagia?
Esophageal candidiasis
Especially if oral thrush is present.
What is the key diagnostic method for vulvovaginal candidiasis?
Demonstration of characteristic blastosphere and hyphal yeast forms in vaginal secretions
Clinical presentation is also considered.
What is the recommended treatment for uncomplicated vulvovaginal candidiasis?
Fluconazole 150 mg PO for one dose (AII)
Topical azoles are also effective.
Is routine primary prophylaxis recommended for mucosal candidiasis?
No
Acute therapy is highly effective, and prophylaxis can lead to drug-resistant strains.
What is the contraindication for oteseconazole during pregnancy?
Fetal malformations including ocular toxicity
It is also contraindicated in females of reproductive potential due to its long half-life.
What is the treatment duration for severe or recurrent vulvovaginal candidiasis?
Oral fluconazole (100–200 mg) PO daily or topical antifungals for ≥7 days (AII)
Regimens may vary for recurrent cases.
What is the significance of drug-drug interactions in the treatment of mucosal candidiasis?
Systemic azoles may have significant interactions with ARV drugs
Therapeutic drug monitoring (TDM) may be necessary.
Which antifungal is the drug of choice for oropharyngeal candidiasis?
Oral fluconazole at 100 to 200 mg once a day
It is superior to topical therapy except during pregnancy.
What are the alternative therapies for esophageal candidiasis?
- Itraconazole oral solution 200 mg PO daily (AI)
- Isavuconazole 400 mg PO as a loading dose
- Voriconazole 200 mg PO or IV twice daily (BI)
- Lipid formulation of amphotericin B 3–4 mg/kg IV daily (BI)
- Echinocandins (caspofungin, micafungin, anidulafungin) (BI)
Higher relapse rates with echinocandins than with fluconazole.
What is a common clinical manifestation of oropharyngeal candidiasis aside from plaque-like lesions?
Angular cheilosis
This condition can also be caused by Candida.
What is the risk associated with the chronic use of azoles?
Development of resistance
Chronic use may promote drug-resistant strains.
What is the alternative treatment for azole-refractory Candida glabrata vaginitis?
Boric acid 600 mg vaginal suppository once daily for 14 days (BII)
This is for cases where traditional azole treatments fail.
What is the role of antiretroviral therapy in preventing mucosal candidiasis?
It is the most effective means to prevent disease
Immune restoration is also critical.
What type of therapy is recommended for pregnant individuals with oral candidiasis?
Topical therapy
Oral fluconazole should be avoided in the first trimester.
What is the significance of oral fluconazole’s efficacy compared to topical therapies for oropharyngeal candidiasis?
Oral fluconazole is more convenient and generally better tolerated
It is also effective for treating esophageal candidiasis.
What gastrointestinal adverse effects were seen with the 100-mg, once-daily isavuconazole regimen?
Higher rate compared to fluconazole and other isavuconazole regimens.
Which antifungal agents effectively treat esophageal candidiasis?
- Posaconazole
- Voriconazole
- Amphotericin B (lipid formulations)
- Echinocandins (caspofungin, micafungin, anidulafungin)
What is the recommended action if a patient does not respond to antifungal therapy within 7 days?
Endoscopy is recommended to identify other potential causes of esophagitis or drug-resistant Candida.
What are the first-line treatments for uncomplicated vulvovaginal candidiasis in most people with HIV?
- Oral fluconazole
- Topical azoles (clotrimazole, butoconazole, miconazole, tioconazole, terconazole)
- Oral ibrexafungerp
What is the new treatment option for recurrent vulvovaginal candidiasis approved in 2022?
Oteseconazole
What are the dosing regimens for oteseconazole in treating recurrent vulvovaginal candidiasis?
600 mg on Day 1, 450 mg on Day 2, followed by once-weekly 150 mg doses starting at Day 14 for 11 weeks.
What class of drug is ibrexafungerp?
b-glucan synthase inhibitor in the class of triterpenoids.
What was the reported effectiveness of ibrexafungerp in recurrent vulvovaginal candidiasis?
65.4% absence of recurrent infection through week 24 compared to 53.1% with placebo.
Is there a need for special considerations regarding the initiation of ART in people with mucocutaneous candidiasis?
No, treatment with ART does not need to be delayed.
What should be monitored if azole therapy is anticipated for more than 21 days?
Liver function and the QTc interval.
What is the definition of antifungal treatment failure?
Persistence of signs or symptoms of oropharyngeal or esophageal candidiasis within 7 days of therapy.
What is the recommended treatment for azole-refractory oropharyngeal or esophageal candidiasis?
Posaconazole immediate-release oral suspension.
What is the recommended dose of IV amphotericin B for treating azole-refractory disease?
Usually effective for treating azole-refractory disease.
What is the recommendation for chronic suppressive therapy for recurrent candidiasis?
Not usually recommended unless there are frequent or severe recurrences.
What is the recommended suppressive therapy for oropharyngeal candidiasis?
Fluconazole 100 mg PO once daily or three times weekly.
What is the recommendation regarding chemoprophylaxis during pregnancy?
Should not be initiated or should be discontinued in people with HIV who become pregnant.
What is the risk associated with oral fluconazole in the first trimester of pregnancy?
Risk of spontaneous abortion and cardiac defects.
What is recommended for invasive or refractory esophageal Candida infections during the first trimester?
Substitution of amphotericin B for fluconazole.
What should be considered when deciding to use secondary prophylaxis for recurrent candidiasis?
- Effect on well-being and quality of life
- Need for prophylaxis against other fungal infections
- Cost
- Adverse events
- Drug–drug interactions
When can secondary prophylaxis be reasonably discontinued?
When CD4 count increases to >200 cells/mm3 following initiation of ART.
What is the experience level of itraconazole use in pregnancy?
Experience is limited
Human data are not available for posaconazole; however, it was associated with skeletal abnormalities in animal studies.
What fetal risks are associated with voriconazole use during pregnancy?
Inconclusive or inadequate evidence for fetal risk
An association with cleft palate and renal defects has been seen in rats, and embryotoxicity in rabbits.
Is human data available for the use of voriconazole during pregnancy?
No, human data are not available
Its use is not recommended due to potential risks.
What anomalies have been seen in animals exposed to micafungin?
Multiple anomalies
Ossification defects have been observed with anidulafungin and caspofungin.
What is the recommendation for the use of micafungin, anidulafungin, and caspofungin in pregnancy?
Not recommended due to lack of human data
AIII classification indicates strong recommendation against use.
What are the newly FDA-approved drugs for vulvovaginal candidiasis?
Ibrexafungerp and oteseconazole
Both are contraindicated in pregnancy due to animal study findings.
What fetal malformations have been reported from oteseconazole in animal studies?
Ocular toxicity
This has led to its contraindication during pregnancy.
Should chemoprophylaxis against candidiasis using systemically absorbed azoles be initiated during pregnancy?
No, it should not be initiated
This includes chronic maintenance therapy or secondary prophylaxis.
What should be done regarding prophylaxis with systemic azoles in HIV patients who become pregnant?
Prophylaxis should be discontinued
This is classified as AIII recommendation.
