Oral Infections (fungal)

Question 1

What is the main cause of fungal mouth infections?

Answer 1

Candida sp.

Question 2

What are the 5 main manifestations of oral candida infection?

Answer 2

1. Thrush (acute pseudomembranous candidiasis)
2. Acute erythematous (atrophic) candidiasis
3. Denture stomatitis
4. Chronic hyperplastic candidiasis
5. Angular chelitis (angular stomatitis)

Question 3

What is the management of choice for thrush (acute pseudomembranous candidiasis)?

Answer 3

Management of predisposing conditions

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FIRST LINE:

• nystatin
• miconazole

SECOND LINE:
- Fluconazole

Question 4

What are some predisposing conditions to thrush? (5)

Answer 4

1. Use of inhaled corticosteroids
2. Use of cytotoxic drugs
3. Use of broad-spectrum antibiotics
4. Leukemia or other malignancies
5. HIV

Question 5

How should thrush be managed in a patient taking inhaled corticosteroids?

Answer 5

Advise to rinse mouth or brush teeth immediately after using the inhaler

Question 6

What causes acute erythematous candidiasis? (3)

Answer 6

Relatively uncommon condition associated with:

• corticosteroid use
• broad spectrum abx use
• HIV

Question 7

What is the treatment of choice for acute erythematous candidiasis?

Answer 7

Fluconazole

Question 8

What is the treatment of choice for denture stomatitis (chronic atrophic candidiasis)?

Answer 8

Miconazole oral gel

• patients should cleanse their dentures thoroughly and leave them out as often as possible during the treatment period. To prevent recurrence of the problem, dentures should not normally be worn at night. New dentures may be required if these measures fail despite good compliance

Question 9

In addition to appropriate pharmacotherapy, what advice should be given to patients suffering from denture stomatitis (chronic atrophic candidiasis)?

Answer 9

1. Patients should cleanse their dentures thoroughly and leave them out as often as possible during the treatment period
2. To prevent recurrence of the problem, dentures should not normally be worn at night.
3. New dentures may be required if these measures fail despite good compliance

Question 10

What are potential causes of denture stomatitis other than candida? (3)

Answer 10

1. Chemical or mechanical irritation
2. Bacterial infection
3. Rarely, allergy to the dental base material

Question 11

What is the management of chronic hyperplastic candidiasis (candidal leukoplakia)?

Answer 11

Biopsy is essential due to the increased risk of malignancy

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Systemic fluconazole to eliminate candidal overlay

*patients should be advised to avoid tobacco

Question 12

What are the causes of angular cheilitis (angular stomatitis)?

Answer 12

Commonly associated with:

• denture stomatitis
• nutritional deficiency
• orofacial granulomatosis
• HIV
• candida infection
• bacterial infection (staph or strep)

**often multiple, interacting factors

Question 13

Why are elderly patients predisposed to angular cheilitis (angular stomatitis)

Answer 13

A reduction in facial height related to ageing and tooth loss with maceration in the deep occlusive folds that may subsequently arise, predisposes to infection with yeast (candida) and/or bacteria (staph or strep)

Question 14

What is the empirical treatment of angular cheilitis (angular stomatitis)?

Answer 14

(While underlying cause is being identified and treated, one of the following may be tried…)

FIRST LINE:

• Miconazole cream OR
• Fusidic acid ointment

SECOND LINE: (if unresponsive to initial treatment)
- hydrocortisone with miconazole cream

Question 15

Is nystatin absorbed by the GI tract?

Answer 15

No; applied to the mouth as a suspension to treat local fungal infection

Question 16

How is miconazole applied in the treatment of oral fungal infections?

Answer 16

Applied as an oral gel; miconazole is absorbed by the GIT so potential drug interactions should be taken into account

Question 17

Does miconazole have any antibacterial properties?

Answer 17

Yes; active against some gram-positive bacterial including staph and strep

Question 18

How is fluconazole applied when treating oral fungal infections?

Answer 18

Taken orally for infections that do not respond to topical therapy or when topical therapy cannot be used; reliably absorbed by the GIT and effective

Question 19

When is itraconazole indicated in the treatment of oral fungal infections?

Answer 19

When infections do not respond to fluconazole

Question 20

How should patients be managed when candidal infection fails to respond to 1-2 weeks of treatment with antifungal drugs?

Answer 20

Patient should be sent for investigation to eliminate the possibility of underlying disease; also consider re-infection from genito-urinary or GI disease as well as partner re-infection

Question 21

What is the method of oral candidiasis prevention in immunocompromised patients?

Answer 21

Antiseptic mouthwash

Question 22

What is the main contraindication to the use of fluconazole?

Answer 22

Acute porphyrias

Question 23

Do azole drugs have any notable drug interactions?

Answer 23

Yes, MANY. Azole antifungals are substrates for and inhibitors of CYP450 enzymes and therefor interact with MANY other drugs

Question 24

What is the main drug interaction to avoid when prescribing fusidic acid?

Answer 24

Statins! Fusidic acid has been reported to cause rhabdomyolysis when given with statins

Question 25

Can fusidic acid be used topically for eye infections?

Answer 25

NO; avoid contact of cream or ointment with eyes

Question 26

How long can topical fusidic acid be used?

Answer 26

Max 10 days to avoid development of resistance

Question 27

Can fluconazole be administered during pregnancy?

Answer 27

No, risk of fetal malformation

Question 28

In which patients should fluconazole be administered with caution?

Answer 28

Patients with liver disease (risk of hepatotoxicity)