From the Guidelines
Resistant oral candidiasis should be treated initially with itraconazole solution, with posaconazole suspension or voriconazole as alternative options.
Management Approach
The management approach for resistant oral candidiasis involves the use of antifungal medications, with the choice of medication depending on the severity of the infection and the patient's underlying health status.
- Itraconazole solution is recommended as the initial treatment for fluconazole-refractory infections, with a response rate of 64-80% 1.
- Posaconazole suspension is an effective alternative, with a response rate of approximately 75% 1.
- Voriconazole may also be used as an alternative, although it is associated with a higher rate of adverse events 1.
- Intravenous caspofungin, micafungin, or anidulafungin are reasonable alternatives to the triazoles, particularly in patients with severe infections or those who are unable to tolerate oral medications 1.
Key Considerations
- Long-term suppressive therapy with fluconazole may be effective in preventing recurrent infections, but it is associated with an increased risk of developing resistance 1.
- HAART (Highly Active Antiretroviral Therapy) should be used as adjunctive therapy in HIV-infected patients with oral candidiasis, as it can help to reduce the frequency and severity of infections 1.
- Immunomodulation with adjunctive granulocyte-macrophage colony-stimulating factor or interferon-γ may be considered in patients with refractory oral candidiasis, although the evidence for this approach is limited 1.
From the Research
Management Approach for Resistant Oral Candidiasis
The management of resistant oral candidiasis involves a combination of antifungal agents and other therapeutic approaches. Some of the key considerations include:
- The use of polyenes (nystatin, amphotericin B), azoles (ketoconazole, miconazole, clotrimazole, fluconazole, itraconazole, voriconazole, posaconazole, isavuconazole), and echinocandins (caspofungin, micafungin, anidulafungin) as antifungal agents 2, 3
- The application of topical antifungal drugs, such as nystatin and miconazole, which are effective but may require a long treatment duration 3
- The use of systemic antifungal agents, such as fluconazole, itraconazole, voriconazole, and posaconazole, for treating oral candidiasis that does not respond to topical treatment 3, 4
- The consideration of novel approaches, including the use of probiotics, ibrexafungerp, antibodies, cytokines, and antimicrobial peptides 2, 3
- The importance of addressing local and systemic factors that contribute to the development of oral candidiasis, such as impairment of oral mucosal integrity, hyposalivation, and suppression of cellular immune activity 4, 5
Treatment of Resistant Cases
In cases where oral candidiasis is resistant to conventional treatment, the following approaches may be considered: