From the Guidelines
Resistant oral candidiasis should be treated initially with itraconazole solution, as it has been shown to be effective in 64-80% of patients who are refractory to fluconazole treatment 1.
Treatment Options
- Itraconazole solution: is the preferred initial treatment for fluconazole-refractory oral candidiasis, with a response rate of 64-80% 1.
- Posaconazole suspension: is an alternative treatment option, with a response rate of approximately 75% in patients with refractory oropharyngeal or esophageal candidiasis 1.
- Voriconazole: may also be effective for fluconazole-refractory infections, although it is associated with a higher rate of adverse events 1.
- Echinocandins: such as caspofungin, micafungin, and anidulafungin, are reasonable alternatives to azole agents for refractory candidiasis 1.
Important Considerations
- Antiretroviral therapy: should be used whenever possible for HIV-infected patients with oropharyngeal or esophageal candidiasis, as it can help to reduce the frequency of symptomatic disease 1.
- Immunomodulation: with adjunctive granulocyte-macrophage colony-stimulating factor or interferon-γ may be considered in the management of refractory oral and esophageal candidiasis 1.
- Resistance: to fluconazole and other azoles is a significant concern in the treatment of oral candidiasis, and susceptibility testing should be performed to guide treatment decisions 1.
From the Research
Treatment Options for Resistant Oral Candidiasis
- The treatment of oral candidiasis typically involves the use of antifungal drugs, such as nystatin, fluconazole, and miconazole 2, 3.
- However, the increasing resistance to these drugs has led to the exploration of alternative strategies, including the use of mouthwashes containing chlorhexidine digluconate, cetylpyridinium chloride, and natural antimicrobials like menthol and thymol 2.
- Flavonoids have also been studied for their potential to combat fluconazole-resistant oral candidiasis, with some showing promising results 4.
- Systemic treatment alternatives, such as itraconazole, voriconazole, and posaconazole, may be used for recalcitrant infections 3.
- Novel treatments, including echinocandins and isavuconazole, are also available for the treatment of oral candidiasis 3.
Management of Resistant Cases
- In cases where oral candidiasis is resistant to local treatment, oral administration of combinations of antifungal drugs may be recommended 5.
- Enhancement of cellular immune activity and improvement of nutritional condition may also be necessary for effective treatment 5.
- Removal of dental biofilms or prevention of biofilm development in combination with antifungal drugs may also be effective in treating oral fungal disease 6.
Antifungal Drug Resistance
- Resistance to antifungal drugs is a growing concern, with some Candida species, such as Candida glabrata and C. krusei, being innately less susceptible to azoles 6.
- The main mechanism of high-level fungal azole resistance is energy-dependent drug efflux, and biofilm matrix permeability and stress response in the fungal cell can also contribute to resistance 6.