1. Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents Mucocutaneous Candidiasis Slide Set
Prepared by the AETC National Resource Center based on recommendations from the CDC, National Institutes of Health, and HIV Medicine Association/Infectious Diseases Society of America

2. About This Presentation
These slides were developed using recommendations published in May The intended audience is clinicians involved in the care of patients with HIV.
Users are cautioned that, owing to the rapidly changing field of HIV care, this information could become out of date quickly. Finally, it is intended that these slides be used as prepared, without changes in either content or attribution. Users are asked to honor this intent.
-AETC National Resource Center
May 2013

3. Mucocutaneous Candidiasis: Epidemiology
Oropharyngeal and esophageal candidiasis are common
Most common in patients with CD4 count <200 cells/µL
Prevalence lower in patients on ART
Vulvovaginal candidiasis
Occurs in HIV-noninfected women; does not indicate immunosuppression
In advanced immunosuppression, may be more severe or recur more frequently
Usually caused by Candida albicans; other species (especially C glabrata) seen in advanced immunosuppression, refractory cases
May 2013

4. Mucocutaneous Candidiasis: Clinical Manifestations
Oropharyngeal (thrush):
Pseudomembranous: painless, creamy white plaques on buccal or oropharyngeal mucosa or tongue; can be scraped off easily
Erythematous: patches on anterior or posterior upper palate or tongue
Angular cheilosis
Esophageal:
Retrosternal burning pain or discomfort, odynophagia, fever; on endoscopy, whitish plaques with or without mucosal ulceration
Vulvovaginal:
Creamy discharge, mucosal burning and itching
May 2013

5. Mucocutaneous Candidiasis: Clinical Manifestations (2)
Pseudomembranous candidiasis
Credit: Pediatric AIDS Pictorial Atlas, Baylor International Pediatric AIDS Initiative
Erythematous candidiasis
Credit: D. Greenspan, DSC, BDS; HIV InSite
May 2013

6. Mucocutaneous Candidiasis: Clinical Manifestations (3)
Esophageal candidiasis
Credit: P. Volberding, MD; UCSF Center for HIV Information Image Library
May 2013

7. Mucocutaneous Candidiasis: Diagnosis
Oropharyngeal:
Usually clinical diagnosis
For laboratory confirmation: KOH preparation; culture
Esophageal:
Empiric diagnosis: symptoms and response to trial of therapy (usually appropriate before endoscopy); visualization of lesions + fungal smear or brushings
Endoscopy with histopathology and culture
Vulvovaginal:
Clinical diagnosis, and KOH preparation
May 2013

8. Mucocutaneous Candidiasis: Prevention
Preventing exposure
Candida are common mucosal commensals; no measures to reduce exposure
Primary prophylaxis
Not recommended: mucosal disease has low mortality; acute therapy is effective; concern for drug resistance, drug interactions, expense
May 2013

9. Mucocutaneous Candidiasis: Treatment
Oropharyngeal
Preferred (7-14 days)
Fluconazole 100 mg PO QD
Clotrimazole troches 10 mg PO 5 times daily
Miconazole mucoadhesive buccal tablet 50 mg QD to canine fossa
Alternative
Itraconazole* oral solution 200 mg PO QD
Posaconazole* oral solution 400 mg PO BID x 1, then 400 mg QD
Nystatin suspension 4-6 mL QID or 1-2 flavored pastilles 4-5 times daily
* May have significant drug interactions with certain ARV medications; consult information on drug interactions before coadministering with ARVs. .
May 2013

10. Mucocutaneous Candidiasis: Treatment (3)
Esophageal
Systemic therapy required
Preferred (14-21 days)
Fluconazole 100 mg (up to 400 mg) PO or IV QD
Itraconazole* oral solution 200 mg PO QD
Alternative
Voriconazole* 200 mg PO BID
Posaconazole* 400 mg PO BID
Caspofungin 50 mg IV QD
Micafungin 150 mg IV QD
Anidulafungin 100 mg IV x 1, then 50 mg IV QD
Amphotericin B deoxycholate 0.6 mg/kg IV QD
Amphotericin B (lipid formulation) 3-4 mg/kg IV QD
* May have significant drug interactions with certain ARV medications; consult information on drug interactions before coadministering with ARVs.
May 2013

11. Mucocutaneous Candidiasis: Treatment (5)
Vulvovaginal, uncomplicated
Preferred
Fluconazole 150 mg PO for 1 dose
Topical azoles for 3-7 days
Alternative
Topical nystatin 100,000 units/day for 14 days
Itraconazole oral solution 200 mg QD for 3 days
Severe or recurrent
Fluconazole mg PO or topical antifungal for ≥7 days
May 2013

12. Mucocutaneous Candidiasis: ART Initiation
No special considerations regarding ART initiation
May 2013

13. Mucocutaneous Candidiasis: Monitoring
Response usually rapid (48-72 hours)
Adverse effects:
Rare with topical treatment
For prolonged oral azole treatment (>21 days), monitor for hepatoxicity
No reports of IRIS
May 2013

14. Mucocutaneous Candidiasis: Treatment Failure
Persistence of signs and symptoms after 7-14 days of appropriate therapy
Testing (eg, culture) needed to confirm treatment failure owing to azole resistance
Refractory disease:
Posaconazole effective in 75% of azole-refractory candidiasis
Oral itraconazole effective in most fluconazole-refractory mucosal candidiasis
Consider anidulafungin, caspofungin, micafungin, voriconazole
Amphotericin B usually effective
May 2013

15. Mucocutaneous Candidiasis: Preventing Recurrence
ART and immune reconstitution reduce recurrences
For oropharyngeal or vulvovaginal, chronic maintenance therapy generally not recommended
If frequent or severe recurrences, consider fluconazole 100 mg PO QD or TIW (oral); fluconazole 150 mg PO weekly (vaginal)
For esophageal, consider fluconazole mg PO QD or posaconazole 400 mg PO BID
Azole-refractory oropharyngeal or esophageal candidiasis: recommended until immune reconstitution on ART (if responded to echinocandins, voriconazole, or posaconazole)
May 2013

16. Mucocutaneous Candidiasis: Preventing Recurrence
Stopping secondary prophylaxis:
No data; reasonable to stop when CD4 >200 cells/µL after ART initiation
May 2013

17. Mucocutaneous Candidiasis: Considerations in Pregnancy
Diagnosis: as in nonpregnant adults
Oral or vaginal candidiasis: topical therapy preferred
For invasive or refractory esophageal candidiasis in 1st trimester, amphotericin B recommended (rather than fluconazole or itraconazole)
High-dose fluconazole and itraconazole: teratogenic in animal studies; teratogenic effects not seen in infants born to women receiving single doses
Systemically absorbed azoles should not be used for prophylaxis during pregnancy
Anidulafungin, caspofungin, micafungin, posaconazole, voriconazole are teratogenic in animals; no human data: not recommended
May 2013

18. Websites to Access the Guidelines
May 2013

19. About This Slide Set
This presentation was prepared by Susa Coffey, MD, for the AETC National Resource Center in May 2013
See the AETC NRC website for the most current version of this presentation:
May 2013