University of California, San Francisco Logo

University of California, San Francisco | About UCSF | Search UCSF | UCSF Medical Center

Home > Treatment > OI Adult Guidelines > Candidiasis
Mucocutaneous Candidiasis
gray line
transparent gif
transparent gif
Epidemiology

Oropharyngeal and esophageal candidiasis are common (574Klein RS, Harris CA, Small CB, et al. Oral candidiasis in high-risk patients as the initial manifestation of the acquired immunodeficiency syndrome. N Engl J Med 1984;311:354-8.). The majority of infection is caused by Candida albicans. Fluconazole (or azole) resistance is predominantly the consequence of previous exposure to fluconazole (or other azoles), particularly repeated and long-term exposure (575Rex JH, Rinaldi MG, Pfaller MA. Resistance of Candida species to fluconazole. Antimicrob Agents Chemother 1995;39:1-8., 576Fichtenbaum CJ, Koletar S, Yiannoutsos C, et al. Refractory mucosal candidiasis in advanced human immunodeficiency virus infection. Clin Infect Dis 2000; 30:749-56., 577Maenza JR, Merz WG, Romagnoli MJ, et al. Infection due to fluconazole-resistant Candida in patients with AIDS: prevalence and microbiology. Clin Infect Dis 1997;24:28-34.). In this setting, C. albicans resistance has been accompanied by a gradual emergence of non-albicans Candida species, particularly C. glabrata, as a cause of refractory mucosal candidiasis, particularly in patients with advanced immunosuppression (575Rex JH, Rinaldi MG, Pfaller MA. Resistance of Candida species to fluconazole. Antimicrob Agents Chemother 1995;39:1-8., 578Martins MD, Lozano-Chiu M, Rex JH. Point prevalence of oropharyngeal carriage of fluconazole-resistant Candida in human immunodeficiency virus-infected patients. Clin Infect Dis 1997;25:843-6.).

The occurrence of oropharyngeal or esophageal candidiasis is recognized as an indicator of immune suppression, and these are most often observed in patients with CD4+ counts <200 cells/µL (574Klein RS, Harris CA, Small CB, et al. Oral candidiasis in high-risk patients as the initial manifestation of the acquired immunodeficiency syndrome. N Engl J Med 1984;311:354-8.). In contrast, vulvovaginal candidiasis is common among healthy, adult women and is unrelated to HIV status. Recurrent vulvovaginal candidiasis alone should not be considered a sentinel of HIV infection among women. The introduction of ART has led to a dramatic decline in the prevalence of oropharyngeal and esophageal candidiasis and a marked diminution in cases of refractory disease.

Clinical Manifestations

Oropharyngeal candidiasis is characterized by painless, creamy white, plaque-like lesions of the buccal or oropharyngeal mucosa or tongue surface. Lesions can be easily scraped off with a tongue depressor or other instrument. Less commonly, erythematous patches without white plaques can be seen on the anterior or posterior upper palate or diffusely on the tongue. Angular chelosis is also noted on occasion and might be caused by Candida.

Esophageal candidiasis is occasionally asymptomatic but retrosternal burning pain or discomfort and odynophagia are often present. Endoscopic examination reveals whitish plaques similar to those observed with oropharyngeal disease that might progress to superficial ulceration of the esophageal mucosa, with central or surface whitish exudates.

Candida vulvovaginitis might be mild to moderate and sporadic, similar to that in normal hosts, and be characterized by a white adherent vaginal discharge associated with mucosal burning and itching. In those with advanced immunosuppression, episodes might be more severe and more frequently recurrent. Compared with oropharyngeal candidiasis, vaginal candidiasis is less frequent and rarely refractory to azole therapy.

Diagnosis

Diagnosis of oropharyngeal candidiasis is usually clinical and based on the appearance of lesions. The feature that distinguishes these from oral hairy leukoplakia is the ability to scrape off the superficial whitish plaques. If laboratory confirmation is required, a scraping for microscopic examination for yeast forms using a potassium hydroxide (KOH) preparation provides supportive diagnostic information. Cultures of clinical material identify the species of yeast present.

The diagnosis of esophageal candidiasis requires endoscopic visualization of lesions with histopathologic demonstration of characteristic Candida yeast forms in tissue and culture confirmation of the presence of Candida species. The diagnosis of vulvovaginal candidiasis is based on the clinical presentation coupled with the demonstration of characteristic pseudohyphal yeast forms in vaginal secretions examined microscopically after KOH preparation. Culture confirmation is rarely required but might provide supportive information. Because self-diagnosis of vulvovaginitis is unreliable, microscopic and culture confirmation is required to avoid unnecessary exposure to inappropriate treatments.

Preventing Exposure

Candida organisms are common commensals on mucosal surfaces in healthy persons. No measures are available to reduce exposure to these fungi.

Preventing Disease

Data from prospective controlled trials indicate that fluconazole can reduce the risk for mucosal (e.g., oropharyngeal, esophageal, and vaginal) candidiasis among patients with advanced HIV disease (579Powderly WG, Finkelstein D, Feinberg J, et al. A randomized trial comparing fluconazole with clotrimazole troches for the prevention of fungal infections in patients with advanced human immunodeficiency virus infection. N Engl J Med 1995;332:700-5., 580Schuman P, Capps L, Peng G, et al. Weekly fluconazole for the prevention of mucosal candidiasis in women with HIV infection: a randomized, double-blind, placebo-controlled trial. Ann Intern Med 1997;126:689-96., 581Havlir DV, Dube MP, McCutchan JA, et al. Prophylaxis with weekly versus daily fluconazole for fungal infections in patients with AIDS. Clin Infect Dis 1998;27:1369-75., 582Goldman M, Cloud GA, Wade KD, et al. A randomized study of the use of fluconazole in continuous versus episodic therapy in patients with advanced HIV infection and a history of oropharyngeal candidiasis. Clin Infect Dis 2005;41:1473-80.). However, routine primary prophylaxis is not recommended because mucosal disease is associated with very low attributable mortality, acute therapy is highly effective, prophylaxis can lead to disease caused by drug-resistant species, prophylactic agents can produce drug interactions, and prophylaxis is expensive (DIII). ART does reduce the likelihood of mucosal candidiasis (AI).

Treatment of Disease

Oral fluconazole is as effective and, in certain studies, superior to topical therapy for oropharyngeal candidiasis. In addition, it is more convenient and typically better tolerated. Therefore, oral fluconazole is considered the drug of choice (AI) (583Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis 2004;38:161-89.).

Initial episodes of oropharyngeal candidiasis can be adequately treated with topical therapy, including clotrimazole troches, nystatin suspension or pastilles, or once-daily miconazole mucoadhesive tablets (BII) (584Van Roey J, Haxaire M, Kamya M, Lwanga I, Katabira E. Comparative efficacy of topical therapy with a slow-release mucoadhesive buccal tablet containing miconazole nitrate versus systemic therapy with ketoconazole in HIV-positive patients with oropharyngeal candidiasis. J Acquir Immune Defic Syndr 2004;35:144-50.).

Itraconazole oral solution for 7-14 days is as effective as oral fluconazole but less well tolerated (AI). Posaconazole oral solution (585Vazquez JA, Skiest DJ, Nieto L, et al. A multicenter randomized trial evaluating posaconazole versus fluconazole for the treatment of oropharyngeal candidiasis in subjects with HIV/AIDS. Clin Infect Dis 2006;42:1179-86.) is also as effective as fluconazole and is generally better tolerated than itraconazole (AI). They are alternatives to oral fluconazole, although few situations require that these drugs would be used in preference to fluconazole solely to treat mucosal candidiasis. In a multicenter, randomized study, posaconazole was proven more effective than fluconazole in sustaining clinical success after antifungal therapy was discontinued (585Vazquez JA, Skiest DJ, Nieto L, et al. A multicenter randomized trial evaluating posaconazole versus fluconazole for the treatment of oropharyngeal candidiasis in subjects with HIV/AIDS. Clin Infect Dis 2006;42:1179-86.). Ketoconazole and itraconazole capsules are less effective than fluconazole because of their more variable absorption. Using these agents to treat mucosal candidiasis is not reasonable if the other options are available (DIII).

Systemic antifungals are required for effective treatment of esophageal candidiasis (AI). A 14-21-day course of either fluconazole (oral or IV) or oral itraconazole solution is highly effective (AI). As with oropharyngeal candidiasis, oral ketoconazole or itraconazole capsules are less effective than fluconazole because of variable absorption (DII). Although IV caspofungin (BI) or IV voriconazole (BI) are effective in treating esophageal candidiasis among HIV-infected patients, oral or IV fluconazole remain the preferred therapies (AI).

Two additional parenteral echinocandins, micafungin and anidulafungin, also are approved for the treatment of esophageal candidiasis. Although the three echinocandins are as effective as fluconazole in the treatment of esophageal candidiasis, they all appear to have a greater relapse rate when compared with fluconazole (586de Wet N, Llanos-Cuentas A, Suleiman J, et al. A randomized, double-blind, parallel-group, dose-response study of micafungin compared with fluconazole for the treatment of esophageal candidiasis in HIV-positive patients. Clin Infect Dis 2004;39:842-9., 587Krause DS, Simjee AE, van Rensburg C, et al. A randomized, double-blind trial of anidulafungin versus fluconazole for the treatment of esophageal candidiasis. Clin Infect Dis 2004;39:770-5.). Although symptoms of esophageal candidiasis might be mimicked by other pathogens, a diagnostic trial of antifungal therapy is usually appropriate before endoscopy is used to identify causes of esophagitis (CII).

Vulvovaginal candidiasis in HIV-infected women is usually uncomplicated (90%) and responds readily to short-course oral or topical treatment with any of several therapies, including the following regimens:

  • Oral fluconazole (AII)
  • Topical azoles (clotrimazole, butaconazole, miconazole, ticonazole, or terconazole (AII)
  • Itraconazole oral solution (BII)

Severe or recurrent episodes of vaginitis require oral fluconazole or topical antifungal therapy for ≥7 days (AIII).

ART reduces the frequency of mucosal candidiasis. Refractory cases of mucosal candidiasis typically resolve when immunity improves in response to ART.

IRIS has not been reported in association with episodes of mucosal candidiasis in HIV-positive persons.

Monitoring and Adverse Events, Including Immune Reconstitution Inflammatory Syndrome (IRIS)

For the majority of patients with mucocutaneous candidiasis, response to therapy is rapid, with improvement in signs and symptoms within 48-72 hours. Short courses of topical therapy rarely result in adverse effects, although patients might experience cutaneous hypersensitivity reactions, characterized rash, and pruritus. Oral azole therapy can be associated with nausea, vomiting, diarrhea, abdominal pain, or transaminase elevations. If prolonged azole therapy is anticipated (>21 days), periodic monitoring of liver chemistry studies should be considered (CIII).

The echinocandins thus far appear to be safe and free of substantial side effects; histamine-related infusion toxicity, elevation of transaminase, and rash have been attributed to these drugs. No dose adjustments are required in renal failure.

IRIS has not been described because of Candida.

Management of Treatment Failure or Refractory Mucosal Candidiasis

Refractory oral or esophageal candidiasis is still reported in approximately 4%-5% of HIV-infected persons, typically in those patients with CD4+ counts <50 cells/µL who have received multiple courses of azole antifungals.

Treatment failure is typically defined as signs and symptoms of oropharyngeal or esophageal candidiasis that persist after more than 7-14 days of appropriate therapy. Oral itraconazole solution is effective at least transiently in approximately two thirds of persons with fluconazole-refractory mucosal candidiasis (AII). Posaconazole immediate-release oral suspension (400 mg bid for 28 days) is effective in 75% of patients with azole refractory oropharyngeal and/or esophageal candidiasis (AII) (588Skiest D, Vazquez J, Anstead G, et al. Posaconazole for the treatment of azole-refractory oropharyngeal and esophageal candidiasis in subjects with HIV infection. Clin Infect Dis 2007;44:607-14.).

IV amphotericin B is usually effective and can be used among patients with refractory disease (BII). Both conventional amphotericin B and lipid complex and liposomal amphotericin B have been used (BII).

Amphotericin B oral suspension (1 mL four times daily of the 100 mg/mL suspension) is sometimes effective among patients with oropharyngeal candidiasis who do not respond to itraconazole (CIII). However, this product is not available in the United States.

Azole-refractory esophageal candidiasis also can be treated with posaconazole (AII), anidulafungin (BII), caspofungin (CII), micafungin (CII), or voriconazole (CIII).

Preventing Recurrence

As with primary prophylaxis, the majority of HIV specialists do not recommend secondary prophylaxis (chronic maintenance therapy) for recurrent oropharyngeal or vulvovaginal candidiasis because of the effectiveness of therapy for acute disease, the low mortality associated with mucosal candidiasis, the potential for resistant Candida organisms to develop, the possibility of drug interactions, and the cost of prophylaxis (DIII). However, if recurrences are frequent or severe, oral fluconazole can be used for either oropharyngeal (BI) or vulvovaginal (CI) candidiasis (579Powderly WG, Finkelstein D, Feinberg J, et al. A randomized trial comparing fluconazole with clotrimazole troches for the prevention of fungal infections in patients with advanced human immunodeficiency virus infection. N Engl J Med 1995;332:700-5., 580Schuman P, Capps L, Peng G, et al. Weekly fluconazole for the prevention of mucosal candidiasis in women with HIV infection: a randomized, double-blind, placebo-controlled trial. Ann Intern Med 1997;126:689-96., 581Havlir DV, Dube MP, McCutchan JA, et al. Prophylaxis with weekly versus daily fluconazole for fungal infections in patients with AIDS. Clin Infect Dis 1998;27:1369-75.). A recent randomized clinical trial (582Goldman M, Cloud GA, Wade KD, et al. A randomized study of the use of fluconazole in continuous versus episodic therapy in patients with advanced HIV infection and a history of oropharyngeal candidiasis. Clin Infect Dis 2005;41:1473-80.) has documented that the number of episodes of oropharyngeal candidiasis and other invasive fungal infections was statistically significantly lower in HIV patients with CD4+ count <150 cells/µL when receiving continuous (three times a week) fluconazole versus episodic treatment of recurrences. This clinical trial also proved that the development of clinically significant resistance was not higher in the group of continuous prophylaxis than in the group with episodic administration of fluconazole, provided that patients received ART.

The decision to use secondary prophylaxis should take into account the effect of recurrences on the patient's well-being and quality of life; the need for prophylaxis for other fungal infections; cost, toxicities, and most importantly, drug interactions (589Marty F, Mylonakis E. Antifungal use in HIV infection. Expert Opin Pharmacother 2002;3:91-102.).

For recurrent esophageal candidiasis, daily fluconazole can be used (BI). Oral posaconazole bid is also effective (BII). However, potential azole resistance should be considered when long-term azoles are considered.

Secondary prophylaxis should be instituted in those patients with fluconazole-refractory oropharyngeal or esophageal candidiasis who have responded to echinocandins, voriconazole, or posaconazole therapy because of high relapse rate until ART produces immune reconstitution (CI).

Discontinuing Secondary Prophylaxis (Chronic Maintenance Therapy)

In situations where secondary prophylaxis is instituted, no data support a recommendation regarding discontinuation. On the basis of experience with other OIs, discontinuing secondary prophylaxis when the CD4+ count has risen to 200 cells/µL because of ART would be reasonable (CIII).

Special Considerations During Pregnancy

Pregnancy increases the risk for vaginal colonization with Candida species. Diagnosis of oropharyngeal, esophageal, and vulvovaginal candidiasis is the same as among nonpregnant.

Topical therapy is preferred for treatment of oral or vaginal candidiasis in pregnancy when possible (BIII). Single-dose, episodic treatment with fluconazole has not been associated with birth defects in humans. However, with chronic use of doses of fluconazole of 400 mg or higher in pregnancy, five cases of a syndrome of craniosynostosis, characteristic facies, digital synostosis, and limb contractures have been reported ("fluconazole embryopathy") (590Lopez-Rangel E, Van Allen MI. Prenatal exposure to fluconazole: an identifiable dysmorphic phenotype. Birth Defects Res A Clin Mol Teratol 2005;73:919-23.). On the basis of these data, substitution of amphotericin B for high-dose fluconazole in the first trimester is recommended for invasive or refractory esophageal candidal infections (AIII). Neonates born to women on chronic amphotericin B at delivery should be evaluated for renal dysfunction and hypokalemia. Itraconazole has been teratogenic in animals at high doses, but the metabolic mechanism accounting for these defects is not present in humans, so data are not applicable. Case series in humans do not suggest an increased risk for birth defects with itraconazole, but experience is limited. Posaconazole was associated with skeletal abnormalities in rats at doses similar to human levels and was embryotoxic in rabbits. No human data are available for posaconazole. Voriconazole is FDA category D because of cleft palate and renal defects seen in rats and embryotoxicity in rabbits. No human data on use of voriconazole are available, so use in the first trimester is not recommended. Multiple anomalies are seen in animals with micafungin; ossification defects have been seen with anidulafungin and caspofungin. No human data are available for these drugs, and their use in human pregnancy is not recommended (DIII).

Chemoprophylaxis, either primary or secondary, against oropharyngeal, esophageal, or vaginal candidiasis using systemically absorbed azoles should not be initiated during pregnancy (DIII), and prophylactic azoles should be discontinued for HIV-infected women who become pregnant (AIII).

Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections in adults and adolescents: Candidiasis (mucosal)
Preferred therapy, duration of therapy, chronic maintenanceAlternative therapyOther options/issues
transparent gifgrey bulletChronic or prolonged use of azoles might promote development of resistance
transparent gif
transparent gifgrey bulletHigher relapse rate of esophageal candidiasis with echinocandins than with fluconazole has been reported
transparent gif
transparent gifgrey bulletPatients with fluconazole refractory oropharyngeal or esophageal candidiasis who responded to echinocandin should be started on voriconazole or posaconazole for secondary prophylaxis until ART produces immune reconstitution (CI)
transparent gif

Suppressive therapy is usually not recommended (DIII) unless patients have frequent or severe recurrences. If decision is to use suppressive therapy:

Preferred therapy oropharyngeal candidiasis: initial episodes (7-14 day treatment)
transparent gifgrey bulletFluconazole 100 mg PO daily (AI); or
transparent gif
transparent gifgrey bulletClotrimazole troches 10 mg PO 5 times daily (BII); or
transparent gif
transparent gifgrey bulletNystatin suspension 4-6 mL qid or 1-2 flavored pastilles 4-5 times daily (BII)
transparent gif
transparent gifgrey bulletMiconazole mucoadhesive tablet PO daily (BII)
transparent gif
Alternative therapy oropharyngeal candidiasis: initial episodes (7-14 day treatment)
transparent gifgrey bulletItraconazole oral solution 200 mg PO daily (BI); or
transparent gif
transparent gifgrey bulletPosaconazole oral solution 400 mg PO bid x 1, then 400 mg daily (BI)
transparent gif
Oropharyngeal candidiasis
transparent gifgrey bulletFluconazole 100 mg PO tiw (BI)
transparent gif
transparent gifgrey bulletItraconazole oral solution 200 mg PO daily (CI)
transparent gif
Preferred therapy esophageal candidiasis (14-21 days)
transparent gifgrey bulletFluconazole 100 mg (up to 400 mg) PO or IV daily (AI)
transparent gif
transparent gifgrey bulletItraconazole oral solution 200 mg PO daily (AI)
transparent gif
Alternative therapy esophageal candidiasis (14-21 days)
transparent gifgrey bulletVoriconazole 200 mg PO or IV bid (BI)
transparent gif
transparent gifgrey bulletPosaconazole 400 mg PO bid (BI)
transparent gif
transparent gifgrey bulletCaspofungin 50 mg IV daily (BI)
transparent gif
transparent gifgrey bulletMicafungin 150 mg IV daily (BI)
transparent gif
transparent gifgrey bulletAnidulafungin 100 mg IV x 1, then 50 mg IV daily (BI)
transparent gif
transparent gifgrey bulletAmphotericin B deoxycholate 0.6 mg/kg IV daily (BI)
transparent gif
Esophageal candidiasis
transparent gifgrey bulletFluconazole 100-200 mg PO daily (BI)
transparent gif
transparent gifgrey bulletPosaconazole 400 mg PO bid (BII)
transparent gif
Preferred therapy uncomplicated vulvovaginal candidiasis
transparent gifgrey bulletOral fluconazole 150 mg for 1 dose (AII)
transparent gif
transparent gifgrey bulletTopical azoles (clotrimazole, butoconazole, miconazole, tioconazole, or terconazole) for 3-7 days (AII)
transparent gif
Alternative therapy uncomplicated vulvovaginal candidiasis
transparent gifgrey bulletItraconazole oral solution 200 mg PO daily for 3-7 days (BII)
transparent gif
Vulvovaginal candidiasis
transparent gifgrey bulletFluconazole 150 mg PO once weekly (CII)
transparent gif
transparent gifgrey bulletDaily topical azole (CII)
transparent gif
Preferred therapy fluconazole-refractory oropharyngeal candidiasis or esophageal candidiasis
transparent gifgrey bulletItraconazole oral solution ≥200 mg PO daily (AII)
transparent gif
transparent gifgrey bulletPosaconazole oral solution 400 mg PO bid (AII)
transparent gif
Alternative therapy fluconazole-refractory oropharyngeal candidiasis or esophageal candidiasis
transparent gifgrey bulletAmphotericin B deoxycholate 0.3 mg/kg IV daily (BII)
transparent gif
transparent gifgrey bulletLipid formulation of amphotericin B 3-5 mg/kg IV daily (BII)
transparent gif
transparent gifgrey bulletAnidulafungin 100 mg IV x 1, then 50 mg IV daily (BII)
transparent gif
transparent gifgrey bulletCaspofungin 50 mg IV daily (CII)
transparent gif
transparent gifgrey bulletMicafungin 150 mg IV daily (CII)
transparent gif
transparent gifgrey bulletVoriconazole 200 mg PO or IV bid (CIII)
transparent gif

Fluconazole-refractory oropharyngeal candidiasis (not esophageal)

transparent gifgrey bulletAmphotericin B oral suspension 100 mg/mL (not available in U.S.) -- 1 mL PO qid (CIII)
transparent gif

Preferred therapy complicated (severe or recurrent) vulvovaginal candidiasis
transparent gifgrey bulletFluconazole 150 mg q72h x 2-3 doses (AII)
transparent gif
transparent gifgrey bulletTopical antifungal ≥7 days (AII)
transparent gif

References

574. Klein RS, Harris CA, Small CB, et al. Oral candidiasis in high-risk patients as the initial manifestation of the acquired immunodeficiency syndrome. N Engl J Med 1984;311:354-8.
575. Rex JH, Rinaldi MG, Pfaller MA. Resistance of Candida species to fluconazole. Antimicrob Agents Chemother 1995;39:1-8.
576. Fichtenbaum CJ, Koletar S, Yiannoutsos C, et al. Refractory mucosal candidiasis in advanced human immunodeficiency virus infection. Clin Infect Dis 2000; 30:749-56.
577. Maenza JR, Merz WG, Romagnoli MJ, et al. Infection due to fluconazole-resistant Candida in patients with AIDS: prevalence and microbiology. Clin Infect Dis 1997;24:28-34.
578. Martins MD, Lozano-Chiu M, Rex JH. Point prevalence of oropharyngeal carriage of fluconazole-resistant Candida in human immunodeficiency virus-infected patients. Clin Infect Dis 1997;25:843-6.
579. Powderly WG, Finkelstein D, Feinberg J, et al. A randomized trial comparing fluconazole with clotrimazole troches for the prevention of fungal infections in patients with advanced human immunodeficiency virus infection. N Engl J Med 1995;332:700-5.
580. Schuman P, Capps L, Peng G, et al. Weekly fluconazole for the prevention of mucosal candidiasis in women with HIV infection: a randomized, double-blind, placebo-controlled trial. Ann Intern Med 1997;126:689-96.
581. Havlir DV, Dube MP, McCutchan JA, et al. Prophylaxis with weekly versus daily fluconazole for fungal infections in patients with AIDS. Clin Infect Dis 1998;27:1369-75.
582. Goldman M, Cloud GA, Wade KD, et al. A randomized study of the use of fluconazole in continuous versus episodic therapy in patients with advanced HIV infection and a history of oropharyngeal candidiasis. Clin Infect Dis 2005;41:1473-80.
583. Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis 2004;38:161-89.
584. Van Roey J, Haxaire M, Kamya M, Lwanga I, Katabira E. Comparative efficacy of topical therapy with a slow-release mucoadhesive buccal tablet containing miconazole nitrate versus systemic therapy with ketoconazole in HIV-positive patients with oropharyngeal candidiasis. J Acquir Immune Defic Syndr 2004;35:144-50.
585. Vazquez JA, Skiest DJ, Nieto L, et al. A multicenter randomized trial evaluating posaconazole versus fluconazole for the treatment of oropharyngeal candidiasis in subjects with HIV/AIDS. Clin Infect Dis 2006;42:1179-86.
586. de Wet N, Llanos-Cuentas A, Suleiman J, et al. A randomized, double-blind, parallel-group, dose-response study of micafungin compared with fluconazole for the treatment of esophageal candidiasis in HIV-positive patients. Clin Infect Dis 2004;39:842-9.
587. Krause DS, Simjee AE, van Rensburg C, et al. A randomized, double-blind trial of anidulafungin versus fluconazole for the treatment of esophageal candidiasis. Clin Infect Dis 2004;39:770-5.
588. Skiest D, Vazquez J, Anstead G, et al. Posaconazole for the treatment of azole-refractory oropharyngeal and esophageal candidiasis in subjects with HIV infection. Clin Infect Dis 2007;44:607-14.
589. Marty F, Mylonakis E. Antifungal use in HIV infection. Expert Opin Pharmacother 2002;3:91-102.
590. Lopez-Rangel E, Van Allen MI. Prenatal exposure to fluconazole: an identifiable dysmorphic phenotype. Birth Defects Res A Clin Mol Teratol 2005;73:919-23.
transparent gif