Candidiasis fluconazole-resistant

Twenty percent of HIV-infected patients develop fluconazole-resistant Candida albicans isolates after repeated exposure to fluconazole.33 To treat fluconazole-resistant oropharyngeal candidiasis, daily itraconazole for 2 to 4 weeks may be used. Oral itraconazole solution exhibits a mycological cure rate of 88% and a clinical cure rate of 97% in immunocompromised patients.34 Fluconazole-resistant esophageal candidiasis should be treated with intravenous amphotericin B or caspofungin. 

L. Millon, A. Manteaux, G. Reboux, C. Drobacheff, M. Monod, T. Barale, and Y. Michel-Briand, Fluconazole-resistant recurrent oral candidiasis in human immunodeficiency virus-positive patients persistence of Candida albicans strains with the same genotype,. Clin. Microbiol., 32, 1115, 1994. 

Fluconazole is less toxic and easier to administer than amphotericin B. However, fluconazole resistance among C. albicans has been well described among HIV-infected individuals and is increasing in immunocompetent adults." C. glabrata often has reduced susceptibility to fluconazole. Itraconazole exhibits a similar activity profile to fluconazole and is well known to be active against mucosal forms of candidiasis. However, formal clinical trials using intravenous... 

Treat nipple candidiasis by applying topical ketoconazole, nystatin, or miconazole to the nipples after each feeding and by administering oral nystatin drops to the breast-feeding infant12 (Table 44-5). In severe or recurrent cases, the mother may be treated with oral fluconazole.12,14 Although messy, gentian violet applied topically to both the nipples and the infant s mouth is also effective for resistant cases.12... 

If immunocompromised patients experience frequent or severe recurrences, particularly of esophageal candidiasis, chronic maintenance therapy with fluconazole 100 to 200 mg daily should be considered. In patients with infrequent or mild cases, secondary prophylaxis is not recommended. The rationale for not giving prophylaxis includes availability of effective treatments for acute episodes, risk of developing resistant organisms, potential for drug interactions, and the cost of therapy. 

Management Prolonged and repeated systemic therapy with fluconazole, itraconazole or ketoconazole - always with the risk of development of resistance - is crucial, treatment of an underlying endocrine disorder has no effect on candidiasis. Genetic counseling is indicated. 

Resistance has not been described widely with itraconazole. This may be partly related to the fact that the drug has been used primarily for the treatment of endemic mycoses and not candidiasis. Even in patients never treated with itraconazole, however, C. albicans strains that are resistant to fluconazole also show decreased susceptibility to itraconazole. 

Flucytosine is used in combination with amphotericin B or fluconazole in the treatment of cryptococcosis or (less commonly) candidiasis. The rapid development of resistance to flucytosine, however, precludes its use as single-agent therapy. Mechanisms for drug resistance may include loss of deaminase and decreased permeability to the drug. ... 

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