What is the treatment for esophageal candida after failure of Fluconazole (fluconazole) and Posaconazole (posaconazole)?

Treatment for Esophageal Candidiasis After Failed Fluconazole and Posaconazole

For esophageal candidiasis that has failed both fluconazole and posaconazole therapy, an echinocandin (micafungin 150 mg daily, caspofungin 70-mg loading dose followed by 50 mg daily, or anidulafungin 200 mg daily) for 14-21 days is the recommended treatment. 1

Treatment Algorithm for Refractory Esophageal Candidiasis

First-Line Options After Azole Failure:

1. Echinocandins (Strong recommendation; high-quality evidence)

   • Micafungin: 150 mg IV daily for 14-21 days 1, 2
   • Caspofungin: 70 mg IV loading dose, then 50 mg IV daily for 14-21 days 1, 3
   • Anidulafungin: 200 mg IV daily for 14-21 days 1

2. Alternative Options:

   • Voriconazole: 200 mg (3 mg/kg) twice daily orally or IV for 14-21 days 1
   • Amphotericin B deoxycholate: 0.3-0.7 mg/kg IV daily for 21 days 1

Rationale for Echinocandins as Preferred Therapy

Echinocandins are particularly valuable in this scenario because:

• They have a different mechanism of action from azoles, avoiding cross-resistance issues
• High clinical efficacy rates (comparable to fluconazole in treatment-naïve cases) 1, 4
• Generally well-tolerated safety profile 4
• Strong recommendation with high-quality evidence in the most recent guidelines 1

Special Considerations

Identification of Causative Species

• Consider obtaining cultures to identify the Candida species and determine susceptibility patterns, as non-albicans Candida species may have different resistance profiles 1
• C. glabrata and C. krusei may be more resistant to azoles 1

Duration of Therapy

• Continue treatment for 14-21 days 1
• Consider endoscopic confirmation of cure in cases of treatment failure 1

Prevention of Recurrence

• For patients with recurrent esophagitis, chronic suppressive therapy with fluconazole 100-200 mg three times weekly is recommended after successful treatment of the acute episode 1
• For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce recurrence risk 1

Monitoring and Follow-up

• Monitor for symptom resolution (dysphagia, odynophagia) within 7 days of initiating therapy 1
• If using echinocandins, monitor liver function tests periodically 1
• Consider follow-up endoscopy in cases of persistent symptoms despite appropriate therapy

Common Pitfalls to Avoid

1. Inadequate duration of therapy: Ensure full 14-21 day course is completed
2. Failure to address underlying immunosuppression: Particularly important in HIV patients
3. Overlooking non-albicans Candida species: These may require different treatment approaches
4. Relapse management: Echinocandins have higher relapse rates than fluconazole, so consider maintenance therapy after successful treatment 1

The 2016 IDSA guidelines provide the most recent and comprehensive recommendations for managing fluconazole-refractory esophageal candidiasis, with echinocandins having the strongest evidence base for efficacy after azole failure 1.