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HIV + candidiasis Flashcards

1
Q

Candida can cultured what which body sites?

A

ORAL cavity
GASTROINTESTINAL tract
GENITAL tract

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2
Q

What proportion of the general population have candida species as a commensal organism?

A

75%

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3
Q

What impact does HIV have on the rate of commensal candida prevalence?

A

HIGHER rates

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4
Q

What is the main pathological manifestation of candida in PLW HIV?

A

Mucosal candidiasis

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5
Q

Which mucosal candidiasis is most common in PLW HIV?

A

OROPHARYNGEAL

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6
Q

What proportion of PLW HIV prior to HAART availability experienced oropharyngeal candidiasis?

A

80-90%

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7
Q

What impact does HIV have on the likelihood of vulvovaginitis from candida?

A

similar to immunocompetent people

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8
Q

Which candida species is the most common cause of candida infection?

A

candida ALBICANS

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9
Q

What increases the risk of NON-ALBICANS candida species in PLW HIV?

A

previous AZOLE therapy

advanced IMMUNOSUPPRESSION

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10
Q

What proportion of candida species are NON-ALBICANS in PLW HIV?

A

30%

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11
Q

Name THREE NON-ALBICANS species of candida?

A

1) GLABRATA
2) KRUSEI
3) DUBLINESIS

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12
Q

Which candida species has INTRINSIC azole RESISTANCE?

A

candida KRUSEI

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13
Q

Through what mechanism does AZOLE resistance develop in candida species?

A 
INTRINSIC resistance
or  
recurrent DRUG EXPOSURE
or
combination of above
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14
Q

What species of candida is inherently multi drug resistant and can be a cause of candidaemia?

A

candida AURIS

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15
Q

What does the immunological response involve against candida species?

A 
T helper(Th) 17 T cells
at
gastronintestinal MUCOSA
or 
SKIN
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16
Q

What impact does HIV have on Th17 T cells?

A

disproportionately DEPLETED
early stages of HIV-associated T cell decline
disrupts host SURVEILLANCE
causing PATHOGENICITY

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17
Q

How long do PLW HIV show impaired T cell response to candida after starting treatment?

A

over TWO (2) years

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18
Q

What other clinical factor or patient demographic increases risk of oropharyngeal candidiasis in PLW HIV?

A

PWID

TB

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19
Q

Do candida species thrive in an acidic or alkaline environment?

A

ACIDIC

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20
Q

What is oropharyngeal candidiasis a predictor of in PLW HIV?

A

worsening IMMUNODEFICIENCY

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21
Q

From onset of oropharyngeal candidiasis, what is the time to development of AIDS in PLW HIV?

A

25 months

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22
Q

What are the various oral presentations of oral candidiasis?

A

ERYTHEMATOUS (red patches + depapillation tongue)
HYPERPLASTIC (white plaques, cannot scrape away)
ANGULAR CHEILITIS

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23
Q

What are the typical symptoms of oropharyngeal candidiasis?

A

ASYMPTOMATIC

SORE mouth or throat

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24
Q

What respiratory symptoms are associated with oropharyngeal candidiasis?

A

increased PHLEGM
chronic COUGH
HOARSENESS

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25
Q

Through what mechanisms can GORD and oesophageal candidiasis co-exist?

A

GORD increased ACIDIC environment
candida THRIVE in acidic environment
mucosal DAMAGE from GORD
candida INVADES more easily

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26
Q

What symptoms are associated with EROSIVE oesophagitis in PLW HIV?

A

HEARTBURN

ACID REGURGITATION

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27
Q

What features of dysphagia should raise the suspicion of oesophageal carcinoma in PLW HIV?

A

no response to CANDIDA treatment

WEIGHT LOSS

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28
Q

What clinical risk factors increase risk of oesophageal cancer?

A

GORD
heavy ALCOHOL use
SMOKING

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29
Q

Does oesophageal candidiasis occur without oropharyngeal candidiasis?

A

NOT typically
may be more likely if on ART
should look for other causes of GI symptoms

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30
Q

What is the sensitivity of clinical diagnosis of oropharyngeal candidiasis vs microbiological detection?

A

SIMILAR

therefore clinical diagnosis is sufficient

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31
Q

Why are empiric or prophylactic antimicrobials not recommended in candida prevention in PLW HIV?

A

promote RESISTANCE

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32
Q

When is candida culture indicated in oropharyngeal candidiasis?

A

PERSISTING signs or symptoms despite anti fungal

RECURRENT infection

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33
Q

Why is candida culture indicated for persisting or recurrent candida infection?

A

identify AZOLE -resistant infection

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34
Q

As an alternative to swabbing a lesion for investigation of mucosal candidiasis what else can be performed?

A

oral or vaginal RINSE

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35
Q

What is the most common medium for culturing candida species?

A

BLOOD agar

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36
Q

What does the presence of candida in blood culture always indicate?

A

INVASIVE disease

candidaemia

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37
Q

When is endoscopy indicated in oesophageal candidiasis?

A

TREATMENT FAILURE
NO OROPHARYNGEAL infection
ALTERNATIVE diagnosis is suspected

38
Q

What is NON-PHARMACOLOGICAL management of oropharyngeal candidiasis?

A

good ORAL HYGIENE

regular REMOVAL or oral BIOFILM

39
Q

What feature of the oral biofilm affects treatment of oropharyngeal candidiasis?

A

inherently resistant to azoles

40
Q

What preparation of pharmacological treatment is most effective at treating oropharyngeal candidiasis?

A

ORAL fluconazole
c/w
topical therapy

41
Q

What dose treatment is recommended for FIRST episode OROPHARYNGEAL candidiasis?

A

Fluconazole 100mg DAILY for 7 days

42
Q

When is a higher or longer course of fluconazole indicated for treatment of oropharyngeal candidiasis?

A

SEVERE or RELAPSED disease

43
Q

What step up regimen is indicated for oropharyngeal candidiasis if first line treatment does not work?

A

INCREASE dose and duration

Fluconazole 200mg, 7-14 days

44
Q

What are the disadvantages of topical therapy for oropharyngeal candidiasis?

A

SLOWER clearance of yeast
higher RELAPSE rate
reduced TOLERABILITY

45
Q

When can topical therapy be used for treatment of oropharyngeal candidiasis?

A

MILD infection
no recurrence
fluconazole intolerance

46
Q

What is the typical topical therapy used in oropharyngeal infection?

A

NYSTATIN (100 000units/mL)

47
Q

What is the regimen for nystatin in oropharyngeal candidiasis?

A

5ml (5 drops) FOUR (4) times a day

7-14 days

48
Q

What other topical agents can be used in oropharyngeal candidiasis?

A

Amphotericin

Clotrimazole

49
Q

What agent can be used to disrupt the oral biofilm formation in oropharyngeal candidiasis?

A

0.2% CHLORHEXIDINE mouthwash

50
Q

What group of people are at increased risk of oral biofilm formation?

A

DENTURE wearers

51
Q

Which TWO agents can be used to treat OESOPHAGEAL candidiasis?

A

FLUCONAZOLE

ITRACONAZOLE

52
Q

What is the typical regimen for OESOPHAGEAL candidiasis?

A

Fluconazole 200-400mg DAILY

14-21 days

53
Q

In mild oesophageal candidiasis, what is the recommended regimen with fluconazole?

A

Fluconazole 200mg

14 days

54
Q

Why is fluconazole the preferred option over itraconazole for treatment of oesophageal candidiasis?

A

better BIOAVAILABILITY

less Drug-drug interactions

55
Q

What preparation of itraconazole should be used for oesophageal candidiasis?

A

oral SOLUTION

56
Q

Why is oral solution preparation of itraconazole recommended if used for oesophageal candidiasis?

A

better BIOAVAILABILITY

57
Q

What factors affect absorption of itraconazole in PLW HIV?

A

low CD4 cell

ANTACID preparations

58
Q

What alteration to proton pump inhibitors (PPI) should be made when treating with fluconazole for oesophageal candidiasis?

A

WITHOLD whilst treatment for
ACUTE or SEVERE candidiasis
(PPI can inhibit activity of fluconazole)

59
Q

If a person requires acid suppression therapy but ideally would withold PPI for treatment of oesophageal candidiasis, what is an alternative?

A

switch to SHORTER-acting treatment

H2 antagonist - RANITIDINE

60
Q

Through what pathway is itraconazole metabolised?

A

cytochrome P450 enzymes

61
Q

Due to its metabolism which drugs should itraconazole not be administered with?

A

ENZYME-inducing - RIFAMYCINS

62
Q

What is the benefit of fluconazole metabolism if requiring to coadminister with enzyme inducers?

A

excreted in urine UNCHANGED

not effected by enzyme inducers

63
Q

What is the alternative class of drugs for treatment of oesophageal candidiasis in people with HIV and liver disease?

A

ECHINOCANDIN

64
Q

When can oral suspension of itraconazole or posaconazole be used for treatment of oropharyngeal candidiasis?

A

fluconazole RESISTANCE

65
Q

What monitoring is required for people on AZOLEs?

A

regular LIVER FUNCTION tests

66
Q

What azole regimen does not require liver function monitoring?

A

LOW-DOSE fluconazole (100mg daily or less)

67
Q

Which azole should be avoided in CONGESTIVE HEART FAILURE?

A

ITRACONAZOLE

68
Q

When is therapeutic drug monitoring indicated in treatment of oropharyngeal candidiasis?

A

non-fluconazole agents
ITRACONAZOLE, POSACONAZOLE, VORICONAZOLE
variable bioavailability

69
Q

Considering various azoles for oesophageal candidiasis, which order should they be used when considering efficacy and toxicity?

A 
FLUCONAZOLE
ITRACONAZOLE
POSACONAZOLE
ISAVUCONAZOLE
VORICONAZOLE
70
Q

If azoles cannot be used for oesophageal candidiasis what classes can be used?

A

ECHINOCANDINS
FUNGINS (caspofungin, micafungin, anidulafungin)
IV amphotericin B

71
Q

Which FUNGIN has a comparable efficacy to fluconazole for treatment of oesophageal candidiasis?

A

MICA-FUNGIN

72
Q

What is the summarised approach to FLUCONAZOLE-REFRACTORY/NON-SUSCEPTIBLE oropharyngeal or oesophageal candidiasis?

A 
try
ITRACONAZOLE
then 
alternative AZOLE
then
ECHINOCANDIN
73
Q

What is the first line treatment for vulvovaginal candidiasis in PLW HIV?

A

CLOTRIMAZOLE pessary 500mg

74
Q

If evidence of severe vulvovaginal candidiasis what additional step can be taken?

A

repeat FLUCONAZOLE oral 72 hours later

75
Q

If recurrent vulvovaginal candidiasis what is the recommended regimen?

A

Fluconazole 150mg every 72 hours (THREE doses)
then
WEEKLY for 6 months

76
Q

What is the recommended treatment for vulvovaginal non-albicans candida if reduced fluconazole susceptibility?

A

NYSTATIN 100 000units PESSARY nightly

14 days

77
Q

What alternative treatments to nystatin can be used for non-albican vulvovaginal candidiasis?

A

5-flucytosine (vaginal cream) + nystatin
amphotericin pessary
boric acid

78
Q

Can fluconazole be used as continuous therapy to reduce recurrence of oropharyngeal or oesophageal candidiasis?

A

possible
no increase in treatment–refractory disease
not recommended

79
Q

What is the difference in dosing of fluconazole for oropharyngeal vs oesophageal candidiasis?

A

ORAL - 100-200mg daily

OESOPHAGEAL - 200-400mg daily

80
Q

ITRACONAZOLE dosing for oropharyngeal or oesophageal candidiasis?

A

ITRACONAZOLE 200mg TWICE daily (oral SOLUTION)

81
Q

POSACONAZOLE dosing for oropharyngeal or oesophageal candidiasis?

A

POSACONAZOLE 400mg TWICE daily
then
400mg DAILY
oral SUSPENSION

82
Q

ISAVUCONAZOLE dosing for oropharyngeal or oesophageal candidiasis?

A 
ISAVUCONAZOLE 200mg LOADING dose
then 
100mg DAILY
or
400mg LOADING
then 
400mg WEEKLY
83
Q

What ART can antifungal AMPHOTERICIN interact with?

A

Tenofovir disoproxil

84
Q

What ART can antifungal CASPOFUNGIN interact with?

A

Efavirenz

Nevirapine

85
Q

What ART can antifungal FLUCONAZOLE interact with?

A 
zidovudine
nevirapine
rilpivirine
cobicistat
tenofovir alafanemide
86
Q

What ART can antifungal ISAVUCONAZOLE interact with?

A

tenofovir alafanemide
Efavirenz
lopinavir/ritonavir
etravirine

87
Q

What ART can antifungal ITRACONAZOLE interact with?

A 
ritonavir or cobicistat
etravirine, efavirenz, nevirapine
maraviroc
rilpivirin
tenofovir alafanemide
88
Q

What ART can antifungal POSACONAZOLE interact with?

A

cobicistat
efavirenz
rilpivirin
ATAZANAVIR

89
Q

What ART can antifungal VORICONAZOLE interact with?

A 
efavirenz
etravirine
lopinavir/ritonavir
rilpivirine
cobicistat
90
Q

What effect does FLUCONAZOLE have on ZIDOVUDINE, NEVIRAPINE, RILPIVIRINE?

A

INCREASED levels

91
Q

What effect does COBICISTAT have on FLUCONAZOLE?

A

INCREASED levels

92
Q

Which ART classes commonly have drug-drug interaction with AZOLES?

A

NNRTI

boosted PIs

DipHIV (14 decks)

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