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6–6 | Clinical Manual for Management of the HIV-Infected Adult/2006
P: Plan
Diagnostic Evaluation
Oropharyngeal candidiasis
Clinical examination alone usually is diagnostic. If the
diagnosis is unclear, organisms may be detected on
smear or culture if necessary.
♦
♦
Potassium hydroxide (KOH) preparation of a smear
collected by gentle scraping of the affected area
with a wooden tongue depressor. Visible hyphae
or blastospheres on KOH mount indicate Candida
infection.
Culture is diagnostic and may detect non-albicans
species in cases resistant to first-line therapies.
Sensitivities may also be needed in such cases to
diagnose azole-resistant infections.
Esophageal candidiasis
A presumptive diagnosis can usually be made with a
recent onset of dysphagia, especially in the presence of
thrush, and empiric antifungal therapy may be started.
If the patient fails to improve clinically after 3-7 days of
therapy, endoscopy should be performed for a definitive
diagnosis.
Treatment
Treatment of oropharyngeal candidiasis
♦ Oral therapy is convenient and very effective as firstline
treatment. Note that azole antifungal drugs are
not recommended for use during pregnancy.
♦
♦
♦
Fluconazole 100 mg once daily for 7-14 days
Alternative topical therapy is less expensive, safe
for use during pregnancy, and effective for mild to
moderate disease. Such therapies include:
♦
♦
Clotrimazole troches dissolved in the mouth 5
times per day for 2 weeks
Nystatin oral suspension 5 mL “swish and
swallow” 4 times daily for 2 weeks
Other alternatives include the following:
♦
♦
Itraconazole oral solution 200 mg once daily for
7-14 days
Itraconazole capsules and ketoconazole 200 mg
once daily for 7-14 days (less effective)
These agents present a greater risk of drug
interactions and hepatotoxicity than do
fluconazole or topical treatments.
Treatment of esophageal candidiasis
♦ Fluconazole 200 mg as an initial dose, then 100 mg
by mouth once daily for 14 days. Intravenous therapy
can be given if the patient is unable to swallow pills.
♦
♦
Itraconazole oral suspension 200 mg once daily for
14 days
Alternative (less effective) treatments include
itraconazole capsules 200 mg once daily or
ketoconazole 200 mg once daily for 14 days
Treatment of refractory candidiasis
Oral or esophageal candidiasis that does not improve
after at least 7-14 days of azole antifungal therapy can
be considered refractory to treatment. The primary
risk factors for development of refractory candidiasis
are CD4 counts