People with healthy immune systems can be exposed to certain viruses, bacteria, or parasites and have minimal reactions to them; however, people living with human immunodeficiency virus (HIV) can face serious health threats from opportunistic infections (OIs). These infections are called opportunistic because they take advantage of a weakened immune system. Opportunistic pathogens are traditionally encountered at CD4 levels below certain thresholds (Figure 28-1). Besides contributing to morbidity and mortality, OIs accelerate the progression of HIV disease. For this reason, guidelines emphasize concurrent antiretroviral therapy (ART) with prophylaxis, treatment, and secondary prophylaxis of OIs.
History of opportunistic infections associated with human immunodeficiency virus. Reproduced with permission from DiPiro JT, Talbert RL, Yee GC, et al: Pharmacotherapy: A Pathophysiologic Approach, 9th ed. New York, NY: McGraw-Hill; 2014.
Mucocutaneous candidiasis is a fungal infection caused by Candida species (most commonly Candida albicans). Candidiasis presents as thrush (a creamy, white plaque-like lesion on the tongue or buccal surface). The most common location for thrush is the oropharynx and esophagus. Esophageal candidiasis may present as retrosternal pain or dysphagia. The diagnosis of thrush is a clinical diagnosis based on the appearance of plaques. A culture may be needed to identify the Candida species. The lesions are painless and can be scraped off with a tongue depressor.
Primary prophylaxis is not routinely recommended for Candidiasis. Routinely administering prophylaxis would increase the likelihood of drug interactions with ART and may promote drug-resistant species. Secondary prophylaxis is recommended for patients with severe recurrences (fluconazole 100-200 mg/d).
Topical treatment may be used for the initial episode of oropharyngeal candidiasis. Topical agents primarily include clotrimazole troches or nystatin suspension. Systemic treatment options include oral fluconazole for 7 to 14 days. Itraconazole and posaconazole are alternatives for oropharyngeal candidiasis. Systemic therapy is recommended for esophageal candidiasis (fluconazole 200-400 mg/d for 14-21 days). Treatment failure may occur in patients with previous azole exposure. Alternative treatment options include itraconazole, voriconazole, caspofungin, micafungin, anidulafungin, and amphotericin B (Table 28-1).
TABLE 28-1Drug Treatment for Oropharyngeal Candidiasis |Favorite Table|Download (.pdf) TABLE 28-1Drug Treatment for Oropharyngeal Candidiasis
|Drug and Availability ||Dose ||Adverse Effects ||Drug/Drug Interactions ||Clinical Notes |
|Clotrimazole troches po: 10 mg troche ||10 mg po 5 × daily || || || |
Compliance with multiple daily dosing
po: 100,000 units/mL (5, 60, 480 mL)
|4-6 mL qid ||GI distress || ||Swish and retain in mouth before swallowing |
po: 50, 100, 150, 200 mg tabs
IV: 200, 400 mg
Oropharygeal: 100-200 mg qd
Esophageal: 200-400 mg qd
|↑ LFTs, GI distress, rash, alopecia ||Amiodarone, benzodiazepines, phenytoin, warfarin, rifampin || |
Inhibits many CYP isoenzymes (2C9, ...