Treatment of Candidal Esophagitis

Oral fluconazole 200-400 mg (3-6 mg/kg) daily for 14-21 days is the first-line treatment for candidal esophagitis. 1

First-Line Treatment Options

Systemic antifungal therapy is always required for candidal esophagitis 1
A diagnostic trial of antifungal therapy is appropriate before performing an endoscopic examination 1
Oral fluconazole 200-400 mg daily for 14-21 days is the recommended first-line treatment with strong recommendation and high-quality evidence 1
Most patients show clinical improvement within 5-7 days of starting therapy 2

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

For fluconazole-refractory cases, itraconazole solution 200 mg daily OR voriconazole 200 mg (3 mg/kg) twice daily (IV or oral) for 14-21 days is recommended 1
Alternative options for fluconazole-refractory disease include 1:
- Echinocandins (micafungin 150 mg daily, caspofungin 70 mg loading dose then 50 mg daily, or anidulafungin 200 mg daily) for 14-21 days
- Amphotericin B deoxycholate 0.3-0.7 mg/kg daily for 21 days
Posaconazole suspension 400 mg twice daily or extended-release tablets 300 mg once daily could be considered, though evidence is weaker 1

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

Treatment should continue for at least 14 days and for at least 2 weeks following resolution of symptoms 3, 4
Itraconazole capsules and ketoconazole are less effective than fluconazole due to variable absorption and should not be used if other options are available 1, 5
Fluconazole has been shown to be superior to ketoconazole for candidal esophagitis in comparative studies 5
Echinocandins, while effective, are associated with higher relapse rates than fluconazole and are only available parenterally 3
For patients with hepatic impairment, dose adjustment of azoles may be necessary 6
For patients with renal impairment receiving fluconazole, dose adjustment based on creatinine clearance is recommended 4

Failure to complete the full treatment course may lead to relapse, even if symptoms resolve quickly 3
Treatment failure is defined as persistence of symptoms after 7-14 days of appropriate therapy 3
Itraconazole solution must be swished in the mouth before swallowing for optimal effect in treating esophageal candidiasis 6
Monitoring liver function tests should be considered if prolonged azole therapy (>21 days) is anticipated 3
Differentiate esophageal candidiasis from other forms of infectious esophagitis such as cytomegalovirus, herpes simplex virus, and non-infectious conditions like eosinophilic esophagitis 7