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Oral candida diflucan,define oral candida,does oral contraceptives cause yeast infection - PDF Review

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During the 1980s and 1990s, numerous reports emerged describing the development of refractory oropharyngeal candidiasis in AIDS patients following prolonged exposure to fluconazole (Diflucan)[1]. In 2008, the Subcommittee for Antifungal Testing of the Clinical Laboratory Standards Institute (CLSI) defined breakpoints for antifungal agents active against Candida species.
Preventing fluconazole-resistant candidiasis is best achieved by avoiding unnecessary use of fluconazole or other systemic antifungal agents and by maximizing the patient's immune status with effective antiretroviral therapy[15,16]. The Guidelines for Prevention and Treatment of Opportunistic Infections in Adults and Adolescents provides recommended preferred and alternative treatment options for fluconazole-refractory oropharyngeal and esophageal candidiasis (Figure 5. Available treatment options for fluconazole-refractory oropharyngeal candidiasis include topical therapy, oral systemic agents, and intravenous therapy. Several reports have described clinical responses to treatment-refractory candidiasis with high-dose fluconazole, but typically resistance will eventually emerge[18].
Oropharyngeal candidiasis occurs frequently among HIV-infected individuals, particularly those with more advanced immune suppression.
Among HIV-infected persons, four different manifestations of oral candidiasis can occur: pseudomembranous candidiasis (thrush), atrophic (erythematous) candidiasis, angular cheilitis (perleche), and rarely, hyperplastic candidiasis. In most clinical situations, the presumptive diagnosis of oral candidiasis is made based on the typical clinical appearance[5]. Routine primary prophylaxis is not recommended[5], mainly because oropharyngeal candidiasis has a very low attributable mortality and regular use of antifungal agents can lead to the development of drug-resistant Candida species[6]. Multiple studies have compared different regimens for the treatment of oropharyngeal candidiasis.
Extensive white plaques along the upper gums and lips in a patient with pseudomembranous candidiasis (thrush). The emergence of fluconazole-resistant candidiasis in HIV-infected persons correlated with the widespread use of fluconazole for oropharyngeal candidiasis during this time period. In addition, most experts do not recommend chronic maintenance therapy following an episode of oropharyngeal candidiasis, or with recurrent episodes of oropharyngeal candidiasis[15]. Treatment of Fluconazole-Refractory Oropharyngeal and Esophageal Candidiasis">Figure 5)[3]. Amphotericin B oral suspension is the best-studied topical therapy for fluconazole-resistant candidiasis.
Several reports have shown good efficacy with itraconazole (Sporanox) oral solution given at a dose of 100 to 200 mg per day in patients with refractory oropharyngeal candidiasis[10,19,20]. The diagnosis of oral candidiasis is a CDC category B diagnosis (in the 1993 CDC classification system)[1].
Pseudomembranous candidiasis typically manifests as creamy white plaque or patches on oral tissues that can usually be scraped off with a tongue blade (Figure 1. For patients who have angular cheilitis with no evidence of intra-oral candidiasis, topical antifungal creams are generally sufficient for therapy (Figure 9. In one small study of patients with oropharyngeal candidiasis, fluconazole (50 mg once daily) appeared superior to ketoconazole (200 mg once daily)[7]. During the 1980s and 1990s, the percentage of fluconazole-resistant Candida species ranged from approximately 5 to 33%[1,2].

Patients with cryptococcal meningitis or recurrent esophageal candidiasis require continuous fluconazole therapy, but systemic antifungal therapy can usually be avoided in patients with less advanced HIV disease and for less serious fungal infections. These guidelines give the highest rating for itraconazole (Sporanox) oral solution and posaconazole (Noxafil) oral solution. The oral solution should be swished in the mouth and then swallowed, as it probably has some topical effect in addition to its systemic effect. In addition, the presence of oropharyngeal candidiasis is an indication for initiating prophylaxis for Pneumocystis pneumonia and for initiating antiretroviral therapy. Patients with pseudomembranous candidiasis can be destinguished from those with oral hairy leukoplakia by scraping the lesions with a tongue blade: the candidiasis plaques are usually removed whereas lesions caused by the oral hairy leukoplakia are not affected by scraping. In a study that involved 334 patients with oral candidiasis, fluconazole (100 mg once daily) and topical clotrimazole troches (10 mg 5 times per day) had similar initial clinical response rates, but clotrimazole was associated with a higher rate of return of symptoms during the second week of follow-up[8].
The opportunistic infections guidelines do not provide a specific duration of therapy, but most experts would recommend at least 10 days of therapy for patients with fluconazole-refractory oropharyngeal candidiasis, with extension of the treatment course if the response is not complete at day 10. In the largest trial involving itraconazole solution, 41 (55%) of 74 patients who failed fluconazole therapy (200 mg once daily) achieved a clinical response by day 28 when treated with itraconazole oral solution (100 mg bid), with 7 days as the median time to response[20]. The development of oral candidiasis generally reflects an imbalance in the normal ecological environment of the oral cavity. Pseudomembranous Candidiasis (Thrush) on Lips and Gums">Figure 2); if the mouth is very dry or if the condition is more chronic, the plaques can be more adherent.
When the clinical diagnosis of oral candidiasis is not clear, the diagnosis can be confirmed by obtaining a direct smear and performing either a potassium hydroxide (KOH) wet mount or a Gram's stain.
In the 2009 United States Guidelines for the Prevention and Treatment of Opportunistic Infections, fluconazole (Diflucan) is recommended as the drug of choice for patients with oropharyngeal candidiasis based on its good efficacy, convenience, and tolerance (Figure 10. Clinical failure refers to persistence or progression of oropharyngeal candidiasis despite antifungal therapy.
Patients with esophageal candidiasis should generally receive a minimum of 21 days of therapy. One study involving 176 HIV-infected patients with fluconazole-refractory oropharyngeal or esophageal candidiasis reported good response rates with oral posaconazole[27]. Although HIV-related immune suppression is typically the most important risk factor for candidiasis, other factors can contribute, including use of antibiotics that change normal bacterial flora, use of corticosteroids, use of chemotherapeutic drugs, presence of diabetes, decreased salivary flow rates, and wearing dentures.
Factors that can affect clinical response include the immune status of the patient, adherence to antifungal therapy, and the potential presence of biofilms formed by Candida organisms[6]. Studies with voriconazole have shown good in vitro activity against fluconazole-susceptible and fluconazole-resistant strains of Candida[21][21]. Considering the strong association of HIV infection and oropharyngeal candidiasis, HIV assessment and testing is recommended for any person who presents with oropharyngeal candidiasis and does not have a known risk factor for oropharyngeal candidiasis[2]. Erythematous candidiasis manifests as flat red patches anywhere on the oral mucosa, most commonly on the hard palate (Figure 3. Obtaining oral fungal cultures is generally reserved for situations when patients do not respond to therapy and anti-fungal resistance is suspected. Most patients who experience clinical failure with fluconazole will have Candida species isolates that show in vitro resistance to fluconazole[6,13].

In addition, voriconazole is also available in an oral form and it has excellent bioavailability. Investigators found voriconazole (200 mg PO bid) to be at least as effective as fluconazole in the treatment of esophageal candidiasis, but this study did not involve fluconazole-refractory candidiasis[22]. Among HIV-infected patients with oral candidiasis, Candida albicans is the most common species involved[3], but non-albicans species, such as such as C.
Erythematous (Atrophic) Candidiasis in Upper Mouth">Figure 3), attached gingival or buccal mucosa, or the dorsal surface of the tongue (Figure 4. In contrast, patients in whom fluconazole-resistant Candida is isolated will often still respond clinically to fluconazole[14].
Alternative therapy consists of itraconazole (Sporanox) oral solution and posaconazole (Noxafil) oral solution. In vitro studies with caspofungin have shown excellent activity against fluconazole-resistant isolates[23] and clinical studies have shown good responses with caspofungin in patients with esophageal candidiasis[24], including fluconazole-refractory cases[25]. From a clinical standpoint, treatment-refractory candidiasis is defined as signs and symptoms of candidiasis that persist for longer than 7 to 14 days after appropriate therapy[3].
Patients with pseudomembranous or erythematous candidiasis often complain of a burning sensation in their mouth and of altered taste.
Fluconazole-Resistant Candidiasis, Mechanism of Action: Altered Binding Site">Figure 3) or from enhanced drug efflux caused by plasma membrane transporters (Figure 4.
Hyperplastic candidiasis is seen with chronic mucosal colonization by Candida with very superficial invasion of the epithelium. In more recent years, clinicians have observed a major decrease in the frequency of fluconazole-resistant oropharyngeal candidiasis, predominantly as a result of the widespread use of potent combination antiretroviral therapy[7].
Fluconazole-Resistant Candidiasis, Mechanism of Action: Efflux Pumps ">Figure 4)[6,7,8,9,10]. Nevertheless, treatment refractory oropharyngeal candidiasis still occurs in approximately 5% of HIV-infected persons[3]. Many of the strains of fluconazole-resistant Candida species display multiple mechanisms of resistance[7]. Initiating antiretroviral therapy would likely play a critical role in minimizing the need to treat recurrent episodes of oropharyngeal candidiasis.
A detailed discussion of drug-resistant candidiasis will be reviewed in Case 4 in this same section (Oral Manifestations). Angular cheilitis usually occurs in conjunction with other intra-oral manifestations of candidiasis.
Because patients with advanced HIV disease and oral candidiasis may have concomitant esophageal candidiasis, they should be asked about dysphagia and odynophagia.

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