What is the recommended treatment for oesophageal candidiasis?

Treatment of Esophageal Candidiasis

Oral fluconazole at a dosage of 200-400 mg (3-6 mg/kg) daily for 14-21 days is the recommended first-line treatment for esophageal candidiasis. 1, 2

First-Line Treatment

• Systemic antifungal therapy is always required for esophageal candidiasis 1
• Oral fluconazole 200-400 mg on day 1, followed by 200-400 mg daily for 14-21 days is the treatment of choice 1, 3
• A diagnostic trial of antifungal therapy is appropriate before performing an endoscopic examination 1, 2
• Treatment should continue for at least 14 days and for at least 2 weeks following resolution of symptoms 3

Alternative Treatments for Patients Unable to Tolerate Oral Therapy

• Intravenous fluconazole at 400 mg (6 mg/kg) daily is recommended for patients who cannot take oral medications 1
• Echinocandins are effective alternatives when oral therapy is not possible:
  • Micafungin 150 mg daily 1
  • Caspofungin 70 mg loading dose, then 50 mg daily 1
  • Anidulafungin 200 mg daily 1
• Amphotericin B deoxycholate (0.3-0.7 mg/kg daily) is a less preferred alternative due to its toxicity profile 1
• Consider de-escalating to oral therapy with fluconazole once the patient can tolerate oral intake 1

Management of Fluconazole-Refractory Disease

• For fluconazole-refractory disease, itraconazole solution 200 mg daily OR voriconazole 200 mg (3 mg/kg) twice daily (IV or oral) for 14-21 days is recommended 1, 4
• Alternative options for fluconazole-refractory disease include:
  • Echinocandins (dosing as above) for 14-21 days 1
  • Amphotericin B deoxycholate 0.3-0.7 mg/kg daily for 21 days 1
• Posaconazole suspension (400 mg twice daily) or extended-release tablets (300 mg once daily) can be considered, though evidence is less robust 1

Management of Recurrent Infections

• For patients with recurrent esophageal candidiasis, chronic suppressive therapy with fluconazole 100-200 mg three times weekly is recommended 1, 2
• For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections 1

Clinical Response and Monitoring

• Most patients show clinical improvement within 48-72 hours of starting appropriate therapy 1, 2
• If symptoms persist for more than 7-14 days despite appropriate therapy, treatment failure should be considered 1, 2
• For prolonged azole therapy (>21 days), periodic monitoring of liver function tests is recommended 1, 2

Common Pitfalls and Considerations

• Itraconazole capsules and ketoconazole are less effective than fluconazole due to variable absorption and should not be used as first-line therapy 1, 2
• Echinocandins, while effective, are associated with higher relapse rates compared to fluconazole and are only available parenterally 2
• Isavuconazole has shown comparable efficacy to fluconazole in clinical trials but is not yet included in major guidelines for this indication 5
• In immunocompromised patients, especially those with cancer, rapid initiation of therapy is essential to prevent complications such as necrotizing esophagitis 6, 7
• Differentiating esophageal candidiasis from other forms of infectious esophagitis (cytomegalovirus, herpes simplex virus) is important for appropriate management 6