Esophageal candidiasis in AIDS. Successful therapy with clotrimazole vaginal tablets taken by mouth

Interventions for prevention and treatment of vulvovaginal candidiasis in women with HIV infection

BACKGROUND

Vulvovaginal candidiasis (VVC) is one of the most common fungal infections that recur frequently in HIV infected women. Symptoms of VVC are pruritis, discomfort, dyspareunia, and dysuria. Vulval infection presents as a morbiliform rash that may extend to the thighs. Vaginal infection is associated with white discharge, and plaques are seen on erythematous vaginal walls.Even though rarely or never resulting in systemic fungal infection or mortality, left untreated these lesions contribute considerably to the morbidity associated with HIV infection. Prevention and treatment of this condition is an essential part of maintaining the quality of life for these individuals.

OBJECTIVES

-To compare the efficacy of various antifungals given vaginally or orally for the treatment and prophylaxis of VVC in HIV-infected women and to evaluate the risks of the same.

SEARCH STRATEGY

The search strategy was comprehensive, iterative and based on that of the HIV/AIDS Cochrane Review Group. The aim was to locate all relevant trials, irrespective of publication status or language. Electronic databases :CENTRAL,Medline, EMBASE, LILACS and CINAHL were searched for randomised controlled trials for the years 1980 to 1st October 2010. WHO ICTRP site and other relevant web sites were also searched for conference abstracts.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of palliative, preventative or curative therapy were considered. Participants were HIV positive women receiving one or more of the following:treatment / prophylaxis for VVC or HAART(Highly Active Antiretroviral Therapy).

DATA COLLECTION AND ANALYSIS

Three authors independently assessed the methodological quality of the trials and extracted data. The quality of the evidence generated was graded using the GRADE PRO approach.

MAIN RESULTS

Our search did not yield any trial investigating treatment of VVC in HIV positive women.Two trials dealing with prophylaxis were eligible for inclusion.One trial (n= 323) favoured the use of weekly Fluconazole as compared to placebo (RR 0.68; 95% CI 0.47 to 0.97).The second trial with three arms of comparison;Clotrimazole,Lactobacillus and Placebo gave no definitive results in preventing an episode of VVC. Clotrimazole against placebo (RR 0.49; 95% CI 0.22 to 1.09), Clotrimazole against lactobacillus (RR 1.11; 95% CI 0.45 to 2.76) and lactobacillus against placebo (RR 0.54 ;95% CI 0.26 to 1.13).

AUTHORS' CONCLUSIONS

Implications for practiceNo trials were found addressing treatment of VVC in HIV positive women.In comparison to placebo,Fluconazole was found to be an effective preventative intervention. However, the potential for resistant Candida organisms to develop might impact the feasibility of implementation.Direction of findings suggests that Clotrimazole and Lactobacillus improved the prophylactic outcomes when compared to placebo.Implications for research There is a need to evaluate drugs and drug regimens for VVC treatment and prophylaxis in HIV positive women through randomised clinical trials. Development of resistance to azoles remains under-studied and more work must be done in this area, so as to determine whether routine prophylaxis for VVC is at all needed or whether adequate ART would be sufficient to prevent recurrent VVC. The viral load in vaginal secretions with or without treatment or prophylaxis has not been studied, this is very relevant to the spread of HIV.

Randomized, double-blind, multicenter study of caspofungin versus amphotericin B for treatment of oropharyngeal and esophageal candidiases

Caspofungin is an antifungal agent of the novel echinocandin class. We investigated its efficacy, safety, and tolerability as therapy for oropharyngeal and/or esophageal candidiasis in a phase II dose-ranging study. Patients were randomized in a double-blind manner to receive either caspofungin acetate (35, 50, or 70 mg) or amphotericin B (0.5 mg/kg of body weight) intravenously once daily for 7 to 14 days. A favorable response required both complete resolution of symptoms and quantifiable improvement of mucosal lesions 3 to 4 days after discontinuation of study drug. Efficacy was assessed using a modified intent-to-treat analysis. No hypothesis testing of efficacy was planned or performed. Of 140 enrolled patients, 63% had esophageal involvement and 98% were infected with the human immunodeficiency virus (HIV) (median CD4 count, 30/mm(3)). A modestly higher proportion of patients in each of the caspofungin groups (74 to 91%) achieved favorable responses compared to amphotericin B recipients (63%), but there was considerable overlap in the 95% confidence intervals surrounding these point estimates. Similar trends were found in the subgroups with esophageal involvement, a history of fluconazole failure, and CD4 counts of < or =50/mm(3). A smaller proportion of patients receiving any dose of caspofungin experienced drug-related adverse events compared to patients given standard doses of conventional amphotericin B (P < 0.01). Caspofungin provided a generally well-tolerated parenteral therapeutic option for HIV-infected patients with oropharyngeal and/or esophageal candidiasis in this study.

The natural history of esophageal candidiasis after successful treatment in patients with AIDS

BACKGROUND/AIMS

Antifungal therapy cures esophageal candidiasis in most patients with acquired immunodeficiency syndrome, but the subsequent course of these patients is not established. This study examines the natural history of esophageal candidiasis after successful treatment.

METHODS

Patients with endoscopic and clinical resolution of esophageal candidiasis after therapy were followed up prospectively with monthly clinical assessment and repeat endoscopy every 3 months or earlier if esophageal symptoms recurred or if the patient was to begin antifungal therapy for another reason.

RESULTS

Thirty-five patients met entry criteria; 21 agreed to enroll. The patients were followed up for a mean of 23 +/- 4 weeks after their initial posttreatment endoscopy. Nineteen patients (90%) had recurrent esophageal candidiasis at a mean of 11 +/- 2 weeks (range, 3-36 weeks). The 19 patients had 31 recurrences; 25 (81%) occurred < or = 10 weeks after documented cure of the prior episode of esophageal candidiasis. Twenty-two (71%) of the 31 recurrent episodes were symptomatic, and only 9 (29%) were associated with oral thrush. All symptomatic recurrences responded to treatment with fluconazole; 1 of 22 (5%) failed to show endoscopic resolution.

CONCLUSIONS

Almost all patients with acquired immunodeficiency syndrome and successfully treated esophageal candidiasis develop a recurrence, usually within 2-3 months. Two thirds are symptomatic and one third are associated with oral thrush. Subsequent episodes of esophageal candidiasis respond well to oral therapy.

Short report: time course of clinical response with fluconazole for Candida oesophagitis in patients with AIDS

BACKGROUND

Although fluconazole is increasingly utilized for the therapy of Candida oesophagitis in patients with AIDS, the time course of response has not been adequately defined.

METHODS

Over a 48-month period, all HIV-infected patients undergoing upper endoscopy at a large city-county hospital were identified prospectively. Symptomatic patients with endoscopic and histopathologically confirmed Candida oesophagitis in whom oral antifungal therapy had not been received within the past three months were treated in an open-label fashion with fluconazole 200 mg on the first day followed by 100 mg daily for two weeks. All patients were followed clinically to determine the rapidity of response.

RESULTS

Eighteen patients were identified; all but two were male. Candida oesophagitis was graded as severe in 13 patients (72%). A complete symptomatic response was seen by five days in seven patients (39%) and by seven days in nine additional patients (cumulative response, 89%). The two other patients had improved by at least 50% at one week, with a complete symptomatic response seen at two weeks.

CONCLUSIONS

Our study confirms anecdotal experience suggesting that fluconazole results in a rapid clinical response for Candida oesophagitis in patients with AIDS. Given this rapidity, a one-week course of empiric treatment with fluconazole for HIV-infected patients with newly developed esophageal symptoms could be used as an appropriate time period to assess a response prior to further diagnostic evaluation with endoscopy.

Esophageal infections: risk factors, presentation, diagnosis, and treatment

Infections of the esophagus are unusual in the general population and strongly imply immunodeficiency, although immunocompetent individuals are not exempt. HIV infection is predominant among risk factors for infectious esophagitis. For all immunocompromised patients, the most frequently identified esophageal pathogens are Candida, CMV, and HSV. Peculiar to HIV-infected patients are idiopathic esophageal ulcers as well as unusual bacteria and parasites. Patterns of presentation differ with each infecting organism, and clinical features should be used as a guide in achieving a correct diagnosis. For example, a patient with AIDS presenting with esophageal symptoms and thrush, along with abdominal pain, nausea, vomiting, and fever, is unlikely to resolve all symptoms with empiric antifungal therapy alone. Parsimony of diagnosis does not hold among immunodeficient patients in whom concurrent infections are common. Accurate and timely diagnoses are essential as effective treatments are available for particular etiologies. Finally, among immunocompromised patients, all esophageal symptoms are not necessarily due to an infection, and possible diagnoses of pill esophagitis, acid-peptic injury, or structural and functional abnormalities should not be overlooked.