Transcript Slide 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
About This Presentation
These slides were developed using recommendations
published in May 2013. 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become out of date quickly.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
http://www.aidsetc.org
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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
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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
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Mucocutaneous Candidiasis:
Clinical Manifestations (2)
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Pseudomembranous candidiasis
Erythematous candidiasis
Credit: Pediatric AIDS Pictorial Atlas, Baylor
International Pediatric AIDS Initiative
Credit: D. Greenspan, DSC, BDS;
HIV InSite
May 2013
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Mucocutaneous Candidiasis:
Clinical Manifestations (3)
Esophageal candidiasis
Credit: P. Volberding, MD; UCSF Center for HIV Information Image Library
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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
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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
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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
 have significant drug interactions with certain ARV medications; consult
* May
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information on drug interactions before coadministering with ARVs.
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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
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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.
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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 100-20 mg PO or topical antifungal for
≥7 days
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Mucocutaneous Candidiasis:
ART
Initiation
 No special considerations regarding
ART initiation
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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
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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
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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 100-200 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)
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Mucocutaneous Candidiasis:
Preventing Recurrence
 Stopping secondary prophylaxis:
 No data; reasonable to stop when CD4
>200 cells/µL after ART initiation
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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
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Websites to Access the Guidelines
 http://www.aidsetc.org
 http://aidsinfo.nih.gov
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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:
http://www.aidsetc.org
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