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 Zambia HIV National Guidelines
 


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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Diagnosis>Opportunistic Infections>
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Candidiasis, oropharyngeal

Amita Gupta, M.D. and Karen Wendel, M.D.
06-23-2009

  • Epidemiology of candidiasis in Zambia not well described, but based on numerous reports from sub-Saharan Africa, candidiasis should be considered a common illness.
  • Dx and management of oropharyngeal candidasis largely the same in Zambia as in developed world.
  • Gentian violet mouth washes with 0.5% aqueous solution (1.5ml) bid or tid is an additional accepted therapy for oropharyngeal candidiasis.
  • WHO/IMAI recommendations for oral thrush which does not respond to a first-line antifungal: Use miconazole gum patch if only nystatin or gentian violet was used previously. If still no response, give fluconazole for 10 days.
  • Posaconazole and echinocandins not readily available in Zambia.

REFERENCES

Zambia Information Author: Larry William Chang, MD, MPH

PATHOGENS

  • Candida albicans: common commensal in human mouth, colon and vagina. Most common cause of oropharyngeal candidiasis (OPC)
  • Other Candida spp. can cause oropharyngeal candidiasis (OPC), including C. tropicalis, C. glabrata, and C. krusei. Some species may not respond as well to standard therapy.

CLINICAL

  • Characterized by white pseudomembranous painless plaques that are easily scraped off ("thrush") of buccal, pharyngeal or tongue areas, and/or erythematous mucosal patches, or angular cheilitis.
  • Risk factors include CD4 <250, recent ABX, diabetes mellitus, and steroid use.
  • Recurrent disease caused by same strain of Candida in ~50%
  • Sx can include oral pain and altered taste perception but many pts are asymptomatic. Retrosternal dysphagia or odynophagia suggest esophageal involvement and should trigger clinicians to use systemic therapy rather than topical antifungals.
  • DDx includes oral hairy leukoplakia. Erythematous mucosal patches of candidiasis can be confused with oral HSV and aphthous ulcerations. White coated tongue without buccal or palate lesions less likely to be thrush.
  • Indication for initiation of PCP prophylaxis and ART

DIAGNOSIS

  • Dx usually made based on clinical appearance.
  • Microscopic examination with KOH prep useful for evaluation of yeast and/or pseudohyphae.
  • Fungal Cx of mucosal lesions allows identification of infecting Candida spp. and enables resistance testing if response to therapy is poor. Cx not useful for Dx, however, as positive Cx may be due to colonization
  • Resistance testing for yeasts has been standardized with NCCLS M27-A2 methodology with defined breakpoints for Candida spp. to fluconazole, itraconazole, and flucytosine.
  • Significant decline in resistance to fluconazole  and itraconazole in HAART era.

TREATMENT

Acute disease: Preferred therapy

  • Clotrimazole troche 10 mg PO 5x/d for 7-14 days after clinical improvement (dissolve in mouth)
  • Nystatin 500,000 U PO 5x/d swish & swallow for 7-14 days after clinical improvement
  • Fluconazole 100 mg PO once-daily x7-14 days
  • Miconazole mucoadhesive tablet PO once daily
Acute disease: Alternative therapy

  • Fluconazole 100-200 mg PO once-daily x7-14 days after clinical improvement
  • Itraconazole (liquid or capsule) 200 mg/day PO (swish & swallow liquid formulation) x7-14 days after clinical improvement
  • Amphotericin B oral suspension (100 mg/mL) 1 mL PO four times a day swish and swallow x7-14 days after clinical improvement. No longer commercially available is USA but can be made by a compounding pharmacy
  • Amphotericin B 0.3 mg/kg per day IV x7-14 days after clinical improvement
  • Caspofungin 50 mg/day IV x7-14 days after clinical improvement
  • Posaconazole oral solution 400 mg PO twice-daily x1d then once-daily, but given broad spectrum and high cost, not recommended for this indication (though listed in 2009 CDC OI guidelines)
Suppression: Preferred therapy

  • Not generally recommended. Considerations for suppressive therapy should include severity and frequency of relapse, presence of esophagitis, cost, drug-drug interactions, risk of azole resistance, and potential for pregnancy.
  • Preferred: Fluconazole 100 mg PO once-daily or 200 mg PO 3x weekly
  • Alternative: Itraconazole (liquid or capsule) 200 mg PO once-daily. Liquid (swish & swallow) preferred as it provides topical therapy and higher systemic levels.
  • Pts without esophagitis can sometimes be suppressed with chronic topical therapy (e.g. clotrimazole). Less convenient, but decreased risk of azole resistance
  • ART is most effective treatment for recurrent OPC

Drug Comments

DrugRecommendations/Comments
Clotrimazole Well tolerated, but nausea, vomiting and diarrhea can occur.
Fluconazole Some species and strains of Candida may exhibit susceptibility-dose/delivery dependent resistance. Treatment of infection with such organisms may require higher doses of fluconazole or itraconazole or a switch to amphotericin B, caspofungin, or a newer azole such as voriconazole. Preferred over other azoles for first-line treatment.
Itraconazole Liquid formulation has better bioavailability than capsule. Extensive drug-drug interactions can complicate use.
Nystatin Has bitter taste,can be associated with GI side effects and needs to be taken several times to day.  Less effective than fluconazoleClotrimazole preferred for topical therapy.
Posaconazole Safe and effective for refractory or azole-resistant oral candidiasis, but not recommended for this indication because of broad-spectrum activity and high cost.

OTHER INFORMATION

  • Pregnant pts should not be treated with azoles. Echinocandins, Clotrimazole and nystatin are category C in pregnancy.
  • Tea tree oil has in vitro activity against Candida spp., even those resistant to azoles.
  • In vitro azole resistance associated with prolonged prior azole exposure, CD4<50
  • IRIS not reported in association with OC

REFERENCES

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