What are the treatments for Candida (fungal infection) esophagitis, Herpes Simplex Virus (HSV) esophagitis, and Cytomegalovirus (CMV) esophagitis?

Treatment for Candida, HSV, and CMV Esophagitis

For esophageal candidiasis, fluconazole 200-400 mg daily for 14-21 days is the treatment of choice, while HSV esophagitis requires acyclovir 400-800 mg five times daily for 14-21 days, and CMV esophagitis necessitates ganciclovir 5 mg/kg IV twice daily for 2-3 weeks. Each infection requires specific targeted therapy based on the causative pathogen.

Candida Esophagitis Treatment

First-line Treatment

• Fluconazole: 200-400 mg daily (oral or IV) for 14-21 days 1
  • Highly effective with excellent clinical response rates
  • Continue treatment until clinical improvement is seen
  • FDA-approved dosing for esophageal candidiasis 2

Alternative Treatments

• Itraconazole oral solution: 200 mg daily for 14-21 days 1

  • Less well tolerated than fluconazole but similar efficacy
  • Should be swished in mouth before swallowing for direct effect 3

• Echinocandins (for fluconazole-resistant cases or intolerance):

  • Caspofungin, micafungin, or anidulafungin IV 1, 4
  • Note: Higher relapse rates compared to fluconazole 1

• Voriconazole: Alternative for fluconazole-resistant cases 1

• Amphotericin B: 0.3-0.7 mg/kg/day IV for refractory cases 1

Treatment Monitoring

• Clinical response typically occurs within 48-72 hours 1
• Monitor liver function tests if prolonged azole therapy (>21 days) is anticipated 1
• Endoscopic confirmation of cure is not routinely required if symptoms resolve

HSV Esophagitis Treatment

First-line Treatment

• Acyclovir: 400-800 mg orally five times daily for 14-21 days
  • For severe cases: 5 mg/kg IV every 8 hours

Alternative Treatments

• Valacyclovir: 1 g orally three times daily for 14-21 days
• Famciclovir: 500 mg orally three times daily for 14-21 days

CMV Esophagitis Treatment

First-line Treatment

• Ganciclovir: 5 mg/kg IV twice daily for 2-3 weeks
  • Consider transition to oral valganciclovir 900 mg twice daily when clinically improved

Alternative Treatment

• Foscarnet: 90 mg/kg IV twice daily for patients with ganciclovir resistance or intolerance
• Cidofovir: 5 mg/kg IV once weekly for 2 weeks, then every 2 weeks

Special Considerations

Immunocompromised Patients

• Consider longer treatment durations for all three infections
• For HIV-infected patients, initiation of antiretroviral therapy is strongly recommended to reduce recurrence 1
• For recurrent candida esophagitis, fluconazole 100-200 mg three times weekly can be used for suppressive therapy 1

Treatment Failure

• For candida esophagitis, treatment failure is defined as persistent symptoms after 7-14 days of appropriate therapy 1
• For fluconazole-refractory candida esophagitis:
  • Itraconazole solution (≥200 mg/day) 1
  • Posaconazole (400 mg twice daily) 1
  • Voriconazole (200 mg twice daily) 1
  • Echinocandins 1, 4

Diagnostic Considerations

• Endoscopy with biopsy and culture is the gold standard for diagnosis of all three types of esophagitis
• For candida esophagitis, a diagnostic trial of antifungal therapy is often appropriate before endoscopy 1
• For HSV and CMV esophagitis, endoscopy with biopsy showing characteristic viral inclusions or positive immunohistochemistry is required for definitive diagnosis

Common Pitfalls and Caveats

• Do not use itraconazole capsules for esophageal candidiasis due to variable absorption 1
• Do not rely on topical agents alone for esophageal candidiasis as systemic therapy is required 1
• Monitor for drug interactions, particularly with azoles and antiretroviral medications
• For patients with AIDS, be aware that multiple pathogens may co-exist, requiring combination therapy
• Failure to improve with appropriate therapy should prompt investigation for resistant organisms or alternative diagnoses