Treatment of Esophageal Candidiasis
Oral fluconazole 200-400 mg daily for 14-21 days is the first-line treatment for esophageal candidiasis, with strong evidence supporting its efficacy and safety. 1, 2, 3
Initial Treatment Approach
First-Line Therapy
- Fluconazole 200-400 mg (3-6 mg/kg) orally once daily for 14-21 days is the preferred treatment based on strong recommendations and high-quality evidence 1, 2, 3
- The FDA-approved dosing is 200 mg on the first day, followed by 100 mg once daily, with doses up to 400 mg/day based on clinical response 4
- However, current IDSA guidelines recommend the higher dose range of 200-400 mg daily from the start, as 100 mg daily may be insufficient for some patients 3
- Treatment should continue for a minimum of 3 weeks and at least 2 weeks following resolution of symptoms 4
When to Consider Empiric Treatment
- A therapeutic trial with fluconazole is cost-effective and appropriate before performing endoscopy in patients with presumed esophageal candidiasis (typically immunocompromised patients with odynophagia/dysphagia) 1, 2
- Most patients experience improvement or resolution of symptoms within 7 days of initiating antifungal therapy 1
Alternative Options for Oral Intolerance
Intravenous Therapy
- Intravenous fluconazole 400 mg (6 mg/kg) daily is the preferred alternative for patients unable to tolerate oral medications 1, 2, 3
- De-escalate to oral fluconazole 200-400 mg daily once the patient can tolerate oral intake 1
Echinocandins
- Micafungin 150 mg IV daily, caspofungin 70 mg loading dose then 50 mg IV daily, or anidulafungin 200 mg IV daily for 14-21 days are effective alternatives 1, 2, 3
- Higher echinocandin doses are used for esophageal disease compared to candidemia to decrease relapse rates 1
- Echinocandins are as effective as fluconazole but have higher relapse rates, which is why they are not first-line 1
Less Preferred Alternative
- Amphotericin B deoxycholate 0.3-0.7 mg/kg IV daily is reserved for patients who cannot tolerate other options 1
Management of Fluconazole-Refractory Disease
Definition and Approach
- Fluconazole-refractory disease is defined as failure to respond after an adequate trial of fluconazole therapy 1
Second-Line Options
- Itraconazole solution 200 mg orally daily OR voriconazole 200 mg (3 mg/kg) orally or IV twice daily for 14-21 days 1, 2, 3
- Itraconazole solution achieves up to 80% response rates in fluconazole-refractory infections and is comparable to fluconazole in treatment-naive patients 1, 5
- Voriconazole is as efficacious as fluconazole and has demonstrated success in fluconazole-refractory mucosal candidiasis 1
Alternative Second-Line Options
- Echinocandins (same doses as above) for 14-21 days OR amphotericin B deoxycholate 0.3-0.7 mg/kg IV daily for 21 days 1, 2
- Posaconazole suspension 400 mg twice daily or extended-release tablets 300 mg once daily may be considered, though this carries a weak recommendation with low-quality evidence 1
Prevention of Recurrence
Chronic Suppressive Therapy
- Fluconazole 100-200 mg orally three times weekly is recommended for patients with recurrent esophageal candidiasis 1, 2, 3
- This regimen is safe for long-term use and effectively decreases recurrence rates 1
HIV-Specific Management
- Antiretroviral therapy is strongly recommended for all HIV-infected patients to reduce the incidence of recurrent infections 1, 2, 3
- The advent of effective antiretroviral therapy has dramatically decreased the prevalence of esophageal candidiasis and cases of refractory disease 1
- Esophageal candidiasis typically occurs at CD4 counts lower than those associated with oropharyngeal disease 1
Important Clinical Considerations
Common Pitfalls to Avoid
- Do not use topical antifungal agents alone—systemic therapy is always required for esophageal candidiasis 3
- Do not use fluconazole capsules and itraconazole solution interchangeably; only itraconazole solution has demonstrated effectiveness for esophageal candidiasis 6
- Do not discontinue therapy prematurely; inadequate treatment duration may lead to recurrence of active infection 4