Candidiasis Mucosal

2011
Notes
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TABLE OF CONTENTS
Introduction ......................................................................... iii Table of Contents................................................................. iv Articles 1. Candidiasis Mucosal ..................................................... 1 2. Mucocutaneus Candidiasis ........................................... 22 3. Candidiasis: Oral, Esophageal, and Vulvovaginal .......... 31 4. Candidal Balanitis ......................................................... 40 5. Mucocutaneus Candidiasis and HIV .............................. 43 6. Molecular and Cellular Mechanisms that Lead to Candida Biofilm Formation........................................... 63 7. Successful Treatment of Chronic Mucocutaneous Candidiasis Caused by Azole-Resistant C. albicans with Posaconazole ............................................................... 84 8. Probiotics for Prevention of Recurrent Vulvovaginal Candidiasis: A Review................................................... 91 9. Prospects for Development of a Vaccine to Prevent and Control Vaginal Candidiasis .......................................... 103
CANDIDIASIS MUCOSAL
SOURCE: http://emedicine.medscape.com/article/1075227-overview AUTHOR: Crispian Scully, MD, PhD, CBE, MDS, MRCS, FDSRCS, FDSRCPS, FFDRCSI, FDSRCSE, FRCPath, FMedSci, FHEA, FUCL, DSc, DChD, DMed(HC), Dr (HC), Professor, Director of Special Projects, Eastman Dental Institute for Oral Health Care Sciences; Professor, Special Needs Dentistry, University College; Professor, Oral Medicine, Pathology and Microbiology, University of London; Visiting Professor Universities of Athens, Bristol, Edinburgh, and Helsinki LAST UPDATED: April 29, 2010
INTRODUCTION Background Candidosis describes a group of yeast like fungal infections involving the skin and mucous membranes. Infection is caused by Candida species, typically, Candida albicans. C albicans is ubiquitous and is found mainly on oral or genital mucosae; it may also be transmissible between consorts.[1] By tradition, the most commonly used divides the infection into 4 types membranous candidosis (thrush), (2) candidosis, (3) chronic hyperplastic atrophic (erythematous) candidosis. classification of oral candidosis including (1) acute pseudoacute atrophic (erythematous) candidosis, and (4) chronic
Chronic hyperplastic candidosis was further subdivided into 4 groups based on localization patterns and endocrine involvement including (1) chronic oral candidosis (candidal leukoplakia), (2) endocrine candidosis syndrome, (3) chronic localized mucocutaneous candidosis, and (4) chronic diffuse candidosis. Thrush (acute pseudomembranous candidiasis) is the term used for the multiple white-fleck appearance of acute candidiasis, which purportedly resembles the appearance of the bird with the same name. Erythematous candidosis is the term used for the red lesions of candidiasis. Pathophysiology
C.albicans is the predominant causal organism of most candidosis. Other species, including Candida krusei, have appeared in persons who are severely immunocompromised. Candida glabrata is an
emerging cause of oropharyngeal candidosis in patients receiving radiation for head and neck cancer.[2] In patients with HIV infection, new species, such as Candida dubliniensis and Candida inconspicua, have been recognized.
Article 1: Candidiasis Mucosal
C albicans is a harmless commensal organism inhabiting the mouths of

almost 50% of the population (carriers); persister cells are clinically relevant, and antimicrobial therapy selects for high-persister strains in vivo.[3] Under certain circumstances, C albicans can become an opportunistic pathogen. Such a suitable circumstance for it to become an opportunist may be a disturbance in the oral flora or a decrease in immune defenses. Acute pseudomembranous candidosis (thrush) Thrush may be observed in healthy neonates or in persons in whom antibiotics, corticosteroids, or xerostomia disturb the oral microflora. Oropharyngeal thrush occasionally complicates the use of corticosteroid inhalers. Immune defects, especially HIV infection, immunosuppressive treatment, leukemias, lymphomas, cancer, and diabetes, may predispose patients to candidal infection. Erythematous candidosis Erythematous candidosis may cause a sore red mouth, especially of the tongue, in patients taking broad-spectrum antimicrobials. It also may be a feature of HIV disease. Median rhomboid glossitis is a red patch occurring in the middle of the dorsum in the posterior area of the anterior two thirds of the tongue and especially is observed in smokers and in those with HIV disease. Chronic mucocutaneous candidosis Chronic mucocutaneous candidosis (CMC) describes a group of rare syndromes, which sometimes include a definable immune defect, in which persistent mucocutaneous candidosis responds poorly to topical treatment. Generally, the more severe the candidosis, the greater the likelihood that immunologic defects (particularly of cell-mediated immunity) can be identified. Recent studies suggest a defect in cytokine (interleukin 2 and interferon-g) production in response to candidal and some bacterial antigens, with reduced TH1 lymphocyte function and enhanced TH2 activity (and increased interleukin 6), and reduced serum levels of immunoglobulin G2 and immunoglobulin G4. Frequency United States Candidosis is common in groups at risk, such as patients who are immunocompromised. Frequency of infection is rising, primarily because of HIV infection and both the increase in candidal species other than C albicans and the resistance to antifungals.
International Candidosis is common in groups at risk, such as patients who are immunocompromised.
Mortality/Morbidity Candidosis may predispose individuals to esophageal spread. Sex Candidosis is reported equally in males and females worldwide, except in areas where males with HIV infection outnumber females. Age Candidosis predominantly occurs in middle-aged or older persons; however, in those with HIV infection, candidal infection primarily occurs in the third and fourth decades.
CLINICAL History Thrush White patches on the surface of the oral mucosa, tongue, or other parts of the body characterize thrush. Lesions develop into confluent plaques that resemble milk curds and can be wiped off to reveal a raw erythematous and sometimes bleeding base. Note the image below.
Pseudomembranous candidosis
Erythematous candidosis Erythematous areas found generally on the dorsum of the tongue, palate, or buccal mucosa are characteristic. Lesions on the dorsum of the tongue present as depapillated areas. Red areas often are seen on the palate of individuals with HIV infection. An associated angular stomatitis may be present. Note the image below.
Erythematous candidosis in HIV/AIDS
Chronic hyperplastic candidosis (candidal leukoplakia)[4] A chronic, discrete, raised lesion that may vary from a small, palpable, translucent, or whitish area to a large, dense, opaque plaque that is hard and rough to the touch (plaquelike lesion) is observed. Homogeneous or speckled areas, which do not rub off (nodular lesions), can be seen. Speckled leukoplakia accounts for 3-50% of candidal leukoplakias. Candidal leukoplakias usually occur on the inside surface of one or both cheeks; they occur less commonly on the tongue.
Chronic multifocal oral candidosis In a minority of individuals, chronic candidal infection may be seen in multiple oral sites with various combinations including (1) angular stomatitis, which is unilateral or bilateral and is encountered mostly in denture wearers; (2) retrocommissural leukoplakia, which is the most constant component of the tetrad; (3) median rhomboid glossitis; and (4) palatal lesions. Additional criteria include (1) lesions of more than 1-month duration; (2) absence of predisposing medical conditions; (3) exclusion of individuals undergoing radiotherapy or administration of the following types of drugs: anti-inflammatory, immunesuppressive, cytotoxic, or psychotropic agents or antibiotics.
This type is most common in male tobacco smokers in their fifth or sixth decade. Antifungal therapy clears the infection and produces clinical improvement; however, recurrence is common, unless smoking can be reduced. Denture-related stomatitis (denture-induced stomatitis, denture sore mouth, chronic atrophic candidosis)[5] Chronic erythema and edema of the mucosa that contacts the fitting surface of the denture are characteristic. The mucosa below the lower denture rarely is involved. Occasional slight soreness is experienced; however, the patient typically is asymptomatic. The typical presenting complaint is angular stomatitis. Note the image below.
Denture-related stomatitis; a common form of oral candidiasis. From Scully C, Flint SF, Bagan JV, Porter SR, Moos K. Atlas of Oral and Maxillofacial Diseases. 2010. Informa, London.
Denture-related stomatitis is classified into 3 clinical types as follows: Localized simple inflammation or a pinpoint hyperemia Erythematous or generalized simple type presenting as more diffuse erythema involving a part of, or the entire, denture-covered mucosa Granular type (inflammatory papillary hyperplasia) commonly involving the central part of the hard palate and the alveolar ridge Angular stomatitis (perlche, angular cheilitis) Lesions affect the angles of the mouth; soreness, erythema, and fissuring are characteristic; diagnosis commonly is associated with denture-related stomatitis. Both yeasts (candidal) and bacteria (especiallyStaphylococcus aureus) may be involved. Note the image below.
Angular stomatitis; a common form of oral candidiasis, typically seen in patients with denture-related stomatitis, especially those in whom the denture needs adjustment. In others, it may be a sign of diabetes, nutritional deficiency, or immune defect.
Angular stomatitis commonly is an isolated initial sign of anemia or vitamin deficiency, such as vitamin B-12, and resolves when the underlying disease has been treated. Iron deficiency anemia and other vitamin deficiencies have been cited as other predisposing factors. In uncommon conditions, such as orofacial granulomatosis, as many as 20% of individuals have angular stomatitis, although candidal species often are not isolated. Angular stomatitis also may be seen in individuals with HIV infection. Median rhomboid atrophy) glossitis (glossal central papillary
Papillary atrophy, which is symmetric and elliptic or rhomboidal in shape, is located centrally at the midline of the tongue, anterior to the circumvallate papillae. Occasionally, median rhomboid glossitis presents with a hyperplastic exophytic or lobulated appearance. Histopathologically, candidal hyphae infiltrate the superficial layers of the parakeratotic epithelium, and a polymorphonuclear leukocyte infiltrate occupies the epithelium, with elongated hyperplastic rete ridges and a lymphocyte infiltration in the corium. However, the condition frequently shows a mixed bacterial-fungal microflora, as has been documented. Other Exfoliative cheilitis may occasionally be associated with Candida species, especially in individuals with HIV infection.
Physical The diagnosis usually is made based on physical examination. Gram stain of a smear (hyphae) or oral rinse may aid in the diagnosis. Differentiate pseudomembranous candidosis from lichen planus. Hairy leukoplakia, leukoplakia, or Fordyce spots occasionally cause confusion. Differentiate erythematous candidosis from other inflammatory stomatitides, lichen planus, and erythroplakia. Causes Members of the genus Candida are the causal organisms of candidosis. Secretion of antimicrobial proteins and peptides is decreased in saliva of patients with oral candidosis.[6 ]The following factors affect candidal carriage and infection: Carriage is more frequent in females than in males; carriage is frequent during the summer months. Increased carriage rates are seen in immunocompromised states (eg, HIV infection), blood group O, and nonsecreting of blood group antigens in the saliva possibly mediated by an effect on C albicansadhesion to epithelia. Carriage of yeast is higher in acidic saliva. Xerostomia increases the carriage of C albicans. Use of psychotropic drugs that cause xerostomia increases carriage of candidal organisms and S aureus. Candidal counts increase during sleep but are reduced by eating a meal and by brushing the teeth. Counts usually are highest first thing in the morning; the organism frequently cannot be isolated when counts are low, except in the early morning. Early morning saliva sample is the most dependable for making a comparison of the candidal population in individuals. Denture-wearing habits affect candidal growth. C albicans counts consistently are low in early morning saliva specimens from edentulous patients not wearing dentures. This is attributed to sleeping without dentures and the consequent alteration in the oral environment. When dentures are worn at night, the early morning saliva candidal count is high; when dentures are not worn at night, the early morning count is the lowest. Increased candidal count following reinsertion of the dentures suggests that plaque on the dentures harbors C albicans. Increase in both the frequency of carriage and the density of candidal colonization in denture wearers compared with dentate individuals suggests that prostheses encourage the presence and growth of candidal species.
Smoking affects candidal infection. Some studies have reported that smoking significantly increased carriage from 30-70%. Smoking increased the risk in persons with HIV infection. Smoking commonly underlies multifocal candidosis and median rhomboid glossitis. Tetracycline therapy affects candidal growth. Candida species can be isolated from the oral cavity with greater prevalence and in greater numbers during tetracycline therapy. Disruption of the ecologic balance disruption can affect growth patterns. Under normal circumstances, it appears unlikely that candidal organisms establish in the mouths of noncarriers; however, if the ecologic balance is altered (by bacterial suppression, alteration of salivary flow, or immunologic deficit), candidal infection may occur. Similarities between carriers and noncarriers of C albicans with respect to age, caries experience, periodontal status, and intraoral temperature indicate that these factors do not influence candidal carriage significantly.
Factors predisposing individuals to oral candidal infections are as follows: Broad-spectrum antimicrobial therapy may predispose individuals to stomatitis or glossitis caused by C albicans. Topical, systemic, and aerosolized corticosteroid use may result in oral yeast infection. Smoking predisposes individuals to chronic atrophic candidosis and other forms of candidosis. Drugs with xerostomic adverse effects (eg, psychopharmaceuticals) are associated with oral candidosis. Xerostomia (as in Sjgren syndrome and after radiotherapy) predisposes individuals to candidosis. Immunologic disorders may play a role. Candidosis is common in patients with HIV infection and other secondary immunodeficiencies, including blood dyscrasias, diabetes, and malignant disease. CMC can be a feature of primary immune defects such as severe combined immune deficiency syndrome. Diabetes may predispose individuals to candidosis.
DIFFERENTIAL DIAGNOSES Oral Leukoplakia, Lichen Planus
Other Problems to Be Considered: Hairy leukoplakia, Fordyce spots
WORKUP Laboratory Studies Quantitative saliva culture is useful in the diagnosis of oral candidosis. Carriers and patients with oral candidal infection can be distinguished reliably (95% confidence limits) on the basis of quantitative culture, since they harbor more than 400 colony-forming units of candidal organisms per mL of saliva. Ask the patient to rinse his or her mouth for 60 seconds with 10 mL of sterile phosphate-buffered saline (PBS; pH 7.2) or sterile water; then, return the oral rinse to the universal container. If the patient wears a denture, remove it prior to sampling. A rapid commercial system (Microstix-Candida or Oricult-N test) for diagnosing oral candidosis is useful for screening patients in the clinical setting, particularly when microbiology laboratories are not in easy access. Because Candida species stain poorly by hematoxylin and eosin, staining with periodic acid-Schiff (PAS), Gridley stain, or Gomori methenamine silver (GMS) stain is used. In both Gridley stain and the PAS procedure, fungi appear pinkish red. GMS technique stains yeast cell walls brown-black as a result of deposition of reduced silver. Presence of blastospores and characteristic pseudohyphae or hyphae in the superficial epithelial tissues identifies the fungus as a species of Candida. GMS staining alone cannot perform the speciation of the organism; therefore, cultural studies also should be used. Blastospores similar to those in Candida species may be seen in histoplasmosis or cryptococcosis, both of which are increasingly prevalent and may manifest orally with increasing frequency in the AIDS epidemic. If only blastospores of candidal organisms are seen in tissue sections of patients in whom infection is suspected, serial sections should be searched carefully for pseudohyphae or hyphae. As tests of humoral immunity, the candida agglutinin test, candida complement-fixation test, candida precipitin test, immunofluorescence, and enzyme-linked immunoassay (ELISA) have been used. Immunity in superficial candidosis and in oral candidosis is predominantly cell mediated. Cell-mediated immunity to C albicans antigens can be demonstrated in most human subjects both by the appearance of delayed skin hypersensitivity to antigens and by in vitro tests of cellular immunity, such as inhibition of leukocyte migration or stimulation of lymphocyte transformation to candidal antigens. In the serologic tests, 4 principal types of Candida antigens have been used, including (1) whole nonviable yeast cells, (2) candidal culture filtrates, (3) cell wall polysaccharides or glycoproteins, and (4) cytoplasmic antigens from mechanically disrupted yeast cells. Serologic tests for candidal organisms are not diagnostic tools, since
the diagnosis can be achieved more readily by clinical evaluation and by smear or culture. With regard to hematologic testing, because oral candidosis frequently is associated with HIV disease, nutritional deficiencies, diabetes, or blood dyscrasias, estimates of corrected whole blood folate, vitamin B12, serum ferritin, glucose, hemoglobin, lymphocyte, and WBC counts can be important. Tests, such as lymphocyte function, serum immunoglobulins, calcium status, or parathyroid hormone levels, are unnecessary except in chronic mucocutaneous candidosis (CMC). Tests of thyroid or adrenocortical function are warranted in selected individuals, since endocrine disorders may be associated with oral candidosis. HIV testing may be indicated. Procedures Although swabs and smears are essential for a microbiological diagnosis of a number of types of oral candidosis, when candidal leukoplakia (chronic hyperplastic candidosis) is suspected, a biopsy specimen should be taken.
TREATMENT Medical Care Attention to the underlying cause helps avoid prolonged or repeated courses of treatment. If antibiotics or corticosteroids (oral or inhaled) are the probable cause, reducing the dose or changing the treatment may help. Resistance of fungi to polyenes is rare, but some Candida species, such as Candida glabrata and Candida krusei, are innately less susceptible to azoles, and Candida albicans can acquire azole resistance).[7 ] Intermittent or prolonged topical antifungal treatment may be necessary when the underlying cause is unavoidable or incurable. In patients with severe immunosuppression, prevention of colonization and infection is the goal because the oropharyngeal region may be the primary source of initial colonization and allows subsequent spread of the infection. Individuals at greatest risk of fungal infection, such as patients with HIV disease and people receiving cancer chemotherapy, immunosuppressive therapy, or prolonged antibiotic therapy, may need prophylactic antifungals. In HIV infection, topical agents often initially control the infection until the increasing immune defect necessitates systemic agents. Topical antifungal agents are available as rinses, tablets, vaginal tablets, and creams. Oral rinses are useful
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for patients with dry mouth who may have difficulty dissolving tablets. Some oral products are sweetened with sugar, predisposing patients to dental caries. Also see the following clinical guideline summaries: Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America Fungal infections. In: Guidelines for prevention and treatment of opportunistic infections among HIV-exposed and HIVinfected children
Denture plaque often contains Candida species. To prevent dentureinduced stomatitis, denture cleansing that includes removal of candidal organisms is a necessary and important factor. Cleansers can be divided into groups according to their primary components: alkaline peroxides, alkaline hypochlorites, acids, disinfectants, and enzymes. Yeast lytic enzymes and proteolytic enzymes are the most effective against the infection. Denture soak solution containing benzoic acid completely eradicates C albicans from the denture surface as it is taken up into the acrylic resin and eliminates the organism from the internal surface of the prosthesis. An oral rinse containing 0.12% chlorhexidine gluconate results in complete elimination of the presence of C albicans on the acrylic resin surface of the denture and in reduction of palatal inflammation. A protease-containing denture soak (alkalize protease) also effectively removes denture plaque, especially when combined with brushing. Chlorhexidine oral rinses also may be of some benefit in the control of oral candidosis. It is important to note that clinical cure is not synonymous with mycologic cure. Diet High-sucrose diets should be avoided.
MEDICATION Antifungal treatment may be necessary for the treatment of candidiasis.
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Fluconazole and HIV infection Fluconazole has been active against oral candidosis in HIV disease and produces remission within approximately 1 week. Fluconazole has gained preference mainly because it is rapidly effective, has a long half-life, and lacks serious adverse effects. Fluconazole 100 mg qd is more effective against oropharyngeal candidosis in HIV infection than nystatin 500,000 U qid or clotrimazole troche 10 mg 5 times per day. Maintenance therapy or intermittent therapy with fluconazole is essential to prevent relapse after cessation of treatment; 50 mg qd prevents recurrence of candidosis as does 150 mg/wk. It appears that a regime of 50 mg/d (single-dose therapy) of fluconazole for 2-3 wk may be adequate to prevent or suppress candidosis in patients infected with HIV. Patients undergoing therapy for metastatic malignancy were assigned randomly to receive fluconazole or placebo as antifungal prophylaxis. Oropharyngeal candidosis developed in only 2% of patients receiving fluconazole but in 28% of patients receiving placebo. These favorable results indicate that fluconazole should be evaluated as antifungal prophylaxis in patients at greatest risk of developing serious fungal infections, such as transplant patients or those receiving chemotherapy for malignant diseases. Fluconazole prophylaxis reduces not only the chance of candidosis in HIV disease but also mycoses such as cryptococcosis. Fluconazole also has been used successfully to treat some patients with acute cryptococcal meningitis in uncontrolled trials, although the time to elimination of the organism in cerebrospinal fluid (CSF) was slower than with amphotericin B. Fluconazole was not as effective in treating cryptococcal meningitis as amphotericin B and flucytosine in a patient with HIV disease; however, fluconazole may be considered in patients with clinically mild disease. Initial use of amphotericin B and flucytosine followed by fluconazole to prevent relapse may be considered. Prevention of recurrent cryptococcal meningitis with daily fluconazole is effective and better tolerated than weekly amphotericin. While amphotericin has been standard therapy, fluconazole recently has been effective in treating patients infected with HIV with coccidioidomycosis. Chronic hyperplastic candidiasis Topical applications of 0.18% isotretinoin may be efficacious.[8 ]
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Article 1: Candidiasis Mucosal Antifungals Currently available azoles are imidazoles (eg, clotrimazole, miconazole, econazole, ketoconazole) and triazoles (eg, fluconazole, itraconazole), which are synthetic antifungals with broad-spectrum activity against a number of yeasts and fungi including candidal organisms. They are fungistatic and expensive. They inhibit fungal cytochrome P450-dependent enzymes, which are essential catalysts for the 14-demethylation of lanosterol in sterol biosynthesis and block synthesis of ergosterol, the principal sterol in fungal cell membranes. One adverse effect of azoles is accumulation of precursors of ergosterol, which may have effects on their own. Diazoles (eg, ketoconazole, miconazole) have more effect on mammalian cytochromes than do triazoles (eg, fluconazole, itraconazole) and tend to have more severe adverse effects. None of the azoles is entirely benign. Hepatotoxicity may be common to all of them, and the potential for endocrine toxicities exists, particularly at high doses. As with any new agent, novel toxicities may be discovered. Azoles are effective antifungals, but resistance increasingly is reported. Development of cross-resistance of C albicans to different azoles during treatment with a single azole derivative has been described. A new triazole, D0870 (Voriconazole), has activity against fluconazoleresistant C albicans. Clotrimazole (Lotrimin, Mycelex, Femizole, Gyne-Lotrimin) Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing death of fungal cells. Reevaluate diagnosis if no clinical improvement after 4 wk. Used as a topical agent only because of GI and neurologic toxicity. As a 10-mg troche used 5 times/d, clotrimazole is effective against oral candidiasis in some patients who are immunocompromised. Less effective than other azoles in patients with HIV infection.
Dosing
Interactions
Adult For 10-mg troches: Hold in mouth and allow to dissolve over a single 15- to 30-min period 5 times/d Pediatric Children: Not established Adolescents: Administer as in adults None reported Documented hypersensitivity Pregnancy B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions
Contraindications Precautions
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Article 1: Candidiasis Mucosal For external use only; avoid contact with eyes; if irritation or sensitivity develops, discontinue use Miconazole (Absorbine, Femizole, Lotrimin, Monistat, Maximum Strength Desenex) For topical treatment of candidosis such as angular stomatitis. Miconazole lacquer is effective for treatment of chronic atrophic candidosis; chewing gum may be effective against intraoral candidosis. Available for parenteral use against systemic mycoses, but injection contains polyethoxylate castor oil, which may provoke allergic reactions.
Dosing
Interactions
Adult Cream and lotion: Apply to affected areas bid for 2-6 wk Powder: Spray or sprinkle liberally on affected area bid Pediatric Administer as in adults None reported Documented hypersensitivity Pregnancy C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus Precautions If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes; given IV may cause liver damage and pruritus, nausea, blood dyscrasias, hyponatremia, hyperlipidemia, and dysrhythmias
Econazole (Spectazole) Effective in cutaneous infections. Interferes with RNA and protein synthesis and metabolism. Disrupts fungal cell wall membrane permeability, causing fungal cell death.
Dosing
Interactions
Adult Apply sparingly on affected areas qd/bid Pediatric Administer as in adults None reported Documented hypersensitivity Pregnancy C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
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Article 1: Candidiasis Mucosal Precautions If sensitivity or irritation develops, discontinue use; for external use only; avoid contact with eyes Ketoconazole (Nizoral) First imidazole agent capable of achieving therapeutic blood levels when given orally. Used in treatment of CMC and candidosis in patients who are immunocompromised. Cream form can be used to treat angular stomatitis. Oral ketoconazole can be effective for treatment of severe oral and esophageal candidosis, but patient compliance often is poor because of taste of drug. Failures also may be related to drug malabsorption, ketoconazole-resistant strains of C albicans, or adverse effects. To be taken with food since gastric acid is essential for dissolution and absorption, but absorption is variable and adverse effects are common. Acidic pH is required for drug absorption, which can be enhanced by taking drug with orange juice, a carbonated beverage, or glutamic acid. Is poorly absorbed from an empty stomach or with concurrent use of medications, such as cimetidine, ranitidine, and other antacids. Poorly absorbed in patients with AIDS because of gastric atrophy and reduced acid production.
Dosing
Interactions
Adult 200-400 mg/d PO Pediatric <2 years: Not established >2 years: 3.3-6.6 mg/kg/d PO once Isoniazid may decrease bioavailability of ketoconazole; coadministration decreases effects of either rifampin or ketoconazole; may increase effect of anticoagulants; may increase toxicity of corticosteroids and cyclosporine (cyclosporine dose can be adjusted); may decrease theophylline levels; ketoconazole may interact with terfenadine (recalled from US market), astemizole (recalled from US market), and cisapride to produce dysrhythmias and increase activity of anticoagulants, cyclosporin, midazolam, and sulfonylureas Documented hypersensitivity; fungal meningitis Pregnancy C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus Precautions Adverse effects may include nausea, rashes, abdominal pain, pruritus, and liver damage; transient disturbance of liver function (eg, increased serum aminotransferase concentrations) is so common that regular monitoring of LFTs is essential in patients on systemic ketoconazole for more than a few days; severe liver damage may
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Article 1: Candidiasis Mucosal occur; blocks hormone steroid synthesis and reduces testosterone levels; adrenocortical suppression may develop; less toxic than amphotericin B but less effective in treatment of severe candidosis and other mycosis; maintenance therapy often is ineffective and both fluconazole and itraconazole may be more effective in prophylaxis Fluconazole (Diflucan) Inhibits fungal ergosterol production essential in cell wall formation by inhibiting the cytochrome c-dependent demethylation step in formation of ergosterol. Has little affinity for mammalian cytochromes, which is believed to explain its low toxicity. Adhesion of candidal organisms to epithelial cells, widely recognized as an essential step in the process of candidal colonization and subsequent infection, is inhibited significantly. Since fluconazole is secreted in saliva in high concentrations, it is tempting to speculate that it may interfere with synthesis or structure of candidal receptors on buccal epithelial cells. Active against most C albicans, although resistance may appear, but is less active against non-C albicans species. Tends to be active against Candida parapsilosis and Candida tropicalis, but less active againstCandida glabrata, and is not active against C krusei. Well absorbed from gut, even in the absence of acidity of the stomach. Can penetrate into other body fluids including CSF. Oral absorption is rapid and almost complete within 2 h. Plasma half-life is approximately 30 h. IV preparations are available for patients who cannot take medication PO. Appears to undergo relatively little metabolism in the body; elimination is predominantly renal. With normal renal function, the serum half-life is approximately 30 h. Concentration of drug in CSF is estimated to be from 50-90% of plasma concentration, suggesting that fluconazole is given best qd and penetrates into CSF and urine in high concentrations. Enters saliva, although salivary levels are higher and persist longer after use of an oral suspension, compared to oral use. Is effective in patients with chronic atrophic oral candidosis, particularly when administered concurrently with oral antiseptic such as chlorhexidine. For patients with CMC in whom relapse after initial remission is expected, a dose of 50 mg produces clinical and mycologic responses in approximately 10 d. Active against oral candidosis in HIV disease and produces remission within approximately 1 wk.
Dosing
Adult 50-100 mg PO qd or 150 mg PO qwk Pediatric 3-6 mg/kg qd for 14-28 d or 6-12 mg/kg qd depending on severity of infection
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Interactions
Levels may increase with hydrochlorothiazide; fluconazole levels may decrease with chronic coadministration of rifampin; coadministration of fluconazole may decrease phenytoin clearance; may increase concentrations of theophylline, tolbutamide, glyburide, and glipizide; effects of anticoagulants may increase with fluconazole coadministration; increases in cyclosporine concentrations may occur when administered concurrently; elevated plasma concentrations of tolbutamide, cyclosporine, phenytoin, and warfarin have been observed after fluconazole administration Documented hypersensitivity Pregnancy C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus Precautions Generally well tolerated; toxicity is mild and infrequent; with usual doses, fluconazole does not appear to suppress synthesis of corticosteroid hormones; nausea, headache, and rashes may occur; although serious cutaneous reactions and hepatitis have occurred in some patients, these reactions appear to be infrequent; may be teratogenic
Itraconazole (Sporanox) Orally active triazole that inhibits ergosterol biosynthesis in fungal cell. Has long half-life and fewer adverse effects than ketoconazole but is expensive and eliminated hepatically. Well absorbed and achieves good distribution in body and may be more active than ketoconazole. Absorption is impaired when gastric acid is reduced or when antacid, rifampicin, or phenytoin is given. May interact with terfenadine, astemizole, and cisapride to produce dysrhythmias and to increase the activity of anticoagulants, cyclosporin, midazolam, and sulfonylureas. Adverse effects have included altered liver function (hepatotoxicity is less than that of ketoconazole) and hypokalemia with hypertension resulting from accumulation of steroids with an aldosteronelike activity, mild leukopenia, nausea, epigastric pain, headache, and edema. Available in 50- and 100-mg cap and 10-mg/mL oral solution. Administering 100-200 mg/d for 2 wk gives good clinical and laboratory results compared to ketoconazole and clotrimazole. GI absorption is reduced in HIV disease. Availability of oral solution may offer advantages over capsules because it acts topically and is easier to swallow for patients with oral candidosis and to administer by NG tube. Active against all candidal species; therefore, may be indicated in patients who are immunocompromised and in whom other antifungals may predispose to selection and overgrowth of resistant species. Has been successful at a dose of 200 mg/d for 4 wk in treatment of candidosis.
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Article 1: Candidiasis Mucosal Absorption from GI tract in persons with HIV infection is approximately one half of that in healthy individuals. Dose of 100 mg PO qd or bid probably is as effective as fluconazole. Available for topical use as a solution. Dose of 200 mg qd is more effective than clotrimazole or ketoconazole.
Dosing
Interactions
Adult 200 mg PO qd; not to exceed 400 mg/d; increase in 100-mg increments if no improvement (administer >200 mg/d in divided doses); 200 mg IV bid for 4 doses, followed by 200 mg/d Pediatric Not established; 100 mg/d suggested for systemic fungal infections Antacids may reduce absorption; edema may occur with coadministration of calcium channel blockers (eg, amlodipine, nifedipine); hypoglycemia may occur with sulfonylureas; may increase tacrolimus and cyclosporine plasma concentrations in high doses; rhabdomyolysis may occur with coadministration of HMG-CoA reductase inhibitors (lovastatin or simvastatin); coadministration with cisapride can cause cardiac rhythm abnormalities and death; may increase digoxin levels; coadministration may increase plasma levels of midazolam or triazolam; phenytoin and rifampin may reduce itraconazole levels (phenytoin metabolism may be altered) Documented hypersensitivity; coadministration with cisapride may cause adverse cardiovascular effects (possibly death) Pregnancy C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus Precautions Caution in hepatic insufficiency
Voriconazole (Vfend) Used for primary treatment of invasive aspergillosis and salvage treatment of Fusarium species or Scedosporium apiospermum infections. A triazole antifungal agent that inhibits fungal CYP450-mediated 14 alpha-lanosterol demethylation, which is essential in fungal ergosterol biosynthesis.
Dosing
Adult Loading dose: 6 mg/kg IV q12h infused over 2 h for 2 doses Maintenance: 4 mg/kg IV q12h infused over 2 h, when able to tolerate PO may switch to 200 mg PO q12h Note: For inadequate response, may increase to 300 mg PO q12h; <40 kg administer oral maintenance dose of 100 mg PO q12h (may increase to 150 mg PO q12h) Pediatric Not established
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Interactions
Contraindications
CYP450 2C19 (highest affinity), 2C9, and 3A4 (minor) substrate and inhibitor; CYP450 inducers (eg, rifampin) have shown to decrease steady state peak plasma levels by up to 93%; may increase serum levels of drugs metabolized by CYP450 2C19 or 2C9, of which some are contraindicated (eg, sirolimus, pimozide, quinidine, cisapride, ergot alkaloids) and others may need more frequent monitoring (eg, cyclosporine, tacrolimus, warfarin, HMG CoA inhibitors, benzodiazepines, calcium channel blockers) Documented hypersensitivity; do not administer IV form with CrCl <50 mL/min (decreased excretion of IV vehicle); coadministration with rifampin, rifabutin, carbamazepine, barbiturates, sirolimus, pimozide, quinidine, cisapride, ergot alkaloids Pregnancy C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus Precautions Decrease maintenance dose with hepatic dysfunction; common adverse effects include visual disturbances, fever, rash, vomiting, nausea, diarrhea, headache, sepsis, peripheral edema, abdominal pain, rash (including Stevens-Johnson syndrome and phototoxicity), and respiratory disorder; rare cases of severe hepatotoxicity have been reported; administer PO 1 h ac or pc
Precautions
FOLLOW-UP Deterrence/Prevention Patients should avoid smoking, xerostomic medication, antibiotics, corticosteroids, and immunosuppressants. Complications Antifungal azole resistance currently is well recognized and is becoming a significant clinical concern, particularly in persons with HIV infection and other immunocompromised conditions. Azole resistance appears to arise because of changes in the target enzyme 14-alpha sterol demethylase, reduced fungal membrane permeability to azoles, changes in delta-5 and delta-6 desaturase, or increased efflux of azoles from the organisms. Ketoconazole resistance has been reported, but is not a concern, since fluconazole is active against at least some ketoconazoleresistant Candida species. Emergence of resistance during fluconazole therapy currently is a true clinical concern, especially in persons who use illegal intravenous
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drugs. The commercially available E test is a simple reliable test useful in detecting fluconazole-resistant C albicans. Fluconazole resistance appears to result from a mutation and may appear in patients who have received no fluconazole, since resistance may be transferred, possibly through sexual transmission. Previous fluconazole use and severe immune defects are risk factors for fluconazole resistance. Intermittent fluconazole or low-dose therapy is more likely than continuous or high-dose therapy to induce resistant species. One US study found that at least 1 fungal species resistant to fluconazole was isolated from 41% of patients with AIDS; other studies found that as many as 20% of patients had fluconazoleresistant oral candidosis. Some evidence exists of cross-resistance of some C albicans and non-C albicans isolates to ketoconazole, fluconazole, and itraconazole, although the clinical significance of this in HIV disease remains to be established. Some studies indicate that ketoconazole and itraconazole may be clinically effective, despite some cross-resistance. Itraconazole in particular may remain effective, although clinical efficacy may be impaired. Approximately 30% of fluconazoleresistant isolates may be resistant to itraconazole. Itraconazole also is effective as a cyclodextrin solution in patients with fluconazole-resistant candidosis. Therapy in fluconazole-resistant cases includes topical amphotericin, higher oral doses of fluconazole (200-600 mg/d), a fluconazole suspension as an oral rinse, or the use of ketoconazole (400 mg/d) or itraconazole (200-400 mg/d). Oral, intravenous, or liposomal amphotericin also may be effective, and, although resistance to oral amphotericin eventually arises, intravenous amphotericin appears to remain effective.
Prognosis The prognosis is good for most infections in the immunocompetent host, but in patients who are immunocompromised, antifungal resistance is commonplace. Patient Education For excellent patient education resources, visit eMedicine's Yeast and Fungal Infections Center. Also, see eMedicine's patient education article Candidiasis (Yeast Infection).
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MISCELLANEOUS Medicolegal Pitfalls Failure to take adequate specimens, possibly resulting in misdiagnosis, can be a pitfall. Early treatment is indicated, and complicating factors should be excluded.
REFERENCES 1. Boriollo MF, Bassi RC, dos Santos Nascimento CM, Feliciano LM, Francisco SB, Barros LM. Distribution and hydrolytic enzyme characteristics of Candida albicans strains isolated from diabetic patients and their non-diabetic consorts. Oral Microbiol Immunol. Dec 2009;24(6):437-50. [Medline]. 2. Redding SW, Dahiya MC, Kirkpatrick WR, et al. Candida glabrata is an emerging cause of oropharyngeal candidiasis in patients receiving radiation for head and neck cancer. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Jan 2004;97(1):47-52. [Medline]. 3. Lafleur MD, Qi Q, Lewis K. Patients with long-term oral carriage harbor high-persister mutants of Candida albicans. Antimicrob Agents Chemother. Jan 2010;54(1):39-44. [Medline]. 4. Sitheeque MA, Samaranayake LP. Chronic hyperplastic candidosis/candidiasis (candidal leukoplakia). Crit Rev Oral Biol Med. 2003;14(4):253-67. [Medline]. 5. Golecka M, Oldakowska-Jedynak U, Mierzwinska-Nastalska E, Adamczyk-Sosinska E. Candidaassociated denture stomatitis in patients after immunosuppression therapy. Transplant Proc. JanFeb 2006;38(1):155-6. [Medline]. 6. Tanida T, Okamoto T, Okamoto A, et al. Decreased excretion of antimicrobial proteins and peptides in saliva of patients with oral candidiasis. J Oral Pathol Med. Nov 2003;32(10):586-94. [Medline]. 7. Niimi M, Firth NA, Cannon RD. Antifungal drug resistance of oral fungi. Odontology. Feb 2010;98(1):15-25. 8. Scardina GA, Ruggieri A, Messina P. Chronic hyperplastic candidosis: a pilot study of the efficacy of 0.18% isotretinoin. J Oral Sci. Sep 2009;51(3):407-10. [Medline]. 9. Fanello S, Bouchara JP, Sauteron M, et al. Predictive value of oral colonization by Candida yeasts for the onset of a nosocomial infection in elderly hospitalized patients. J Med Microbiol. Feb 2006;55:223-8. [Medline]. 10. Lynch DP. Oral candidiasis. History, classification, and clinical presentation. Oral Surg Oral Med Oral Pathol. Aug 1994;78(2):189-93. [Medline]. 11. Rautemaa R, Hietanen J, Niissalo S, Pirinen S, Perheentupa J. Oral and oesophageal squamous cell carcinoma--a complication or component of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED, APS-I). Oral Oncol. Jul 2007;43(6):607-13. [Medline]. 12. Scully C, el-Kabir M, Samaranayake LP. Candida and oral candidosis: a review. Crit Rev Oral Biol Med. 1994;5(2):125-57. [Medline]. 13. Taillandier J, Esnault Y, Alemanni M. A comparison of fluconazole oral suspension and amphotericin B oral suspension in older patients with oropharyngeal candidosis. Multicentre Study Group. Age Ageing. Mar 2000;29(2):117-23. [Medline].
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MUCOCUTANEOUS CANDIDIASIS
SOURCE: http://hivinsite.ucsf.edu/InSite?page=md-agl-cand AUTHORS: Jonathan E. Kaplan,MD1, Constance Benson,MD2, King K. Holmes,MD,PhD3, John Brooks,MD1 Alice Pau,PharmD4, Henry Masur,MD4 - 1CDC, Atlanta, Georgia2 University of California San Diego, San Diego, California 3University of Washington, Seattle, Washington4National Institutes of Health, Bethesda, Maryland DATE PUBLISHED: April 10, 2009
Epidemiology Oropharyngeal and esophageal candidiasis are common1. 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 exposure2,3,4. In this setting, C.albicans resistance has been accompanied by a gradual emergence of non-albicans Candidaspecies, particularly C. glabrata, as a cause of refractory mucosal candidiasis, particularly in patients with advanced immunosuppression2,5. 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/L1. 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.
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Article 2: Mucocutaneus Candidiasis
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,6,7,8,9. 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
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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)10. 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)11. Itraconazole oral solution for 7-14 days is as effective as oral fluconazole but less well tolerated (AI). Posaconazole oral solution12 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 discontinued12. 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 fluconazole13. 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).
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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, ticonazole, or terconazole (AII) Itraconazole oral solution (BII) butaconazole, miconazole,
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/L 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
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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)15. 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) candidiasis6,7,8. A recent randomized clinical trial9 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/L 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 interactions16. 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.
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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/L 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")17. 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).
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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 maintenance Alternative therapy Other options/issues*
Chronic or prolonged use of azoles might promote development of resistance Higher relapse rate of esophageal candidiasis with echinocandins than with fluconazole has been reported Patients 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) *Suppressive therapy is usually not recommended (DIII) unless patients have frequent or severe recurrences. If decision is to use suppressive therapy Oropharyngeal Candidiasis Preferred therapy: initial episodes (7-14 day treatment) Fluconazole 100 mg PO daily (AI); or Clotrimazole troches 10 mg PO 5 times daily (BII); or Nystatin suspension 4-6 mL qid or 1-2 flavored pastilles 4-5 times daily (BII) Miconazole mucoadhesive tablet PO daily (BII) Alternative therapy: initial episodes (7-14 day treatment) Itraconazole oral solution 200 mg PO daily (BI); or Posaconazole oral solution 400 mg PO bid x 1, then 400 mg daily (BI) Other options/issues* Fluconazole 100 mg PO tiw (BI) Itraconazole oral solution 200 mg PO daily (CI) Esophageal Candidiasis Preferred therapy (14-21 days) Fluconazole 100 mg (up to 400 mg) PO or IV daily (AI) Itraconazole oral solution 200 mg PO daily (AI) Alternative therapy (14-21 days) Voriconazole 200 mg PO or IV bid (BI) Caspofungin 50 mg IV daily (BI) Micafungin 150 mg IV daily (BI) Anidulafungin 100 mg IV x 1, then 50 mg IV daily (BI) Amphotericin B deoxycholate 0.6 mg/kg IV daily (BI)
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Article 2: Mucocutaneus Candidiasis Other options/issues* Fluconazole 100-200 mg PO daily (BI) Posaconazole 400 mg PO bid (BII) Uncomplicated Vulvovaginal Candidiasis Preferred therapy Oral fluconazole 150 mg for 1 dose (AII) Topical azoles (clotrimazole, butoconazole, miconazole, tioconazole, or terconazole) for 3-7 days (AII) Alternative therapy Itraconazole oral solution 200 mg PO daily for 3-7 days (BII) Other options/issues* Fluconazole 150 mg PO once weekly (CII) Daily topical azole (CII) Fluconazole-Refractory Oropharyngeal Candidiasis Or Esophageal Candidiasis Preferred therapy Itraconazole oral solution 200 mg PO daily (AII) Posaconazole oral solution 400 mg PO bid (AII) Alternative therapy Amphotericin B deoxycholate 0.3 mg/kg IV daily (BII) Lipid formulation of amphotericin B 3-5 mg/kg IV daily (BII) Anidulafungin 100 mg IV x 1, then 50 mg IV daily (BII) Caspofungin 50 mg IV daily (CII) Micafungin 150 mg IV daily (CII) Voriconazole 200 mg PO or IV bid (CIII)
Alternative therapy fluconazole-refractory oropharyngeal candidiasis or esophageal candidiasis
Fluconazole-refractory oropharyngeal candidiasis (not esophageal)
Amphotericin B oral suspension 100 mg/mL (not available in U.S.) -1 mL PO qid (CIII)
Complicated (Severe Or Recurrent) Vulvovaginal Candidiasis Preferred therapy Fluconazole 150 mg q72h x 2-3 doses (AII) Topical antifungal 7 days (AII)
REFERENCES 1. 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. 2. Rex JH, Rinaldi MG, Pfaller MA. Resistance of Candida species to fluconazole. Antimicrob Agents Chemother 1995;39:1-8. 3. Fichtenbaum CJ, Koletar S, Yiannoutsos C, et al. Refractory mucosal candidiasis in advanced human immunodeficiency virus infection. Clin Infect Dis 2000; 30:749-56. 4. 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. 5. Martins MD, Lozano-Chiu M, Rex JH. Point prevalence of oropharyngeal carriage of fluconazoleresistant Candida in human immunodeficiency virus-infected patients. Clin Infect Dis 1997;25:843-6. 6. 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.
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7. 8. 9. 10. 11. 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. 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. 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. Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis 2004;38:161-89. 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. 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. de Wet N, Llanos-Cuentas A, Suleiman J, et al. A randomized, double-blind, parallel-group, doseresponse study of micafungin compared with fluconazole for the treatment of esophageal candidiasis in HIV-positive patients. Clin Infect Dis 2004;39:842-9. 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. 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. Marty F, Mylonakis E. Antifungal use in HIV infection. Expert Opin Pharmacother 2002;3:91-102. 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.
12. 13. 14. 15. 16. 17.
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CANDIDIASIS: ORAL, ESOPHAGEAL, AND VULVOVAGINAL

SOURCE: http://www.aidsetc.org/aidsetc?page=cm-504_candidiasis;http://www.aidsetc.org/aidsetc?pa ge=cm-505_candidiasis_vulvo AUTHOR(S): the AIDS Education & Training Centers National Resource Center LAST UPDATED: July 2007
CANDIDIASIS ORAL AND ESOPHAGEAL BACKGROUND Oropharyngeal candidiasis ("thrush"), a fungal disease of the oral mucosa and tongue, is the most common intraoral lesion in persons infected with HIV. In the absence of other known causes of immunosuppression, oral thrush in an adult is highly suggestive of HIV infection. Three clinical presentations of thrush are common in people with HIV: pseudomembranous, erythematous, and angular cheilitis. Thrush usually occurs with CD4 counts of <300 cells/L and is not an AIDS-defining illness.
Candida may also infect the esophagus in the form of esophageal
candidiasis which causes dysphagia (difficulty with swallowing) or odynophagia (pain with swallowing). Esophageal candidiasis is an AIDS-defining condition, generally occurring in individuals with CD4 counts of <100 cells/L. It is the most common cause of esophageal infection in persons with AIDS. Oropharyngeal and esophageal candidiasis are most commonly caused byCandida albicans , although occasionally non- albicans species cause disease and may be resistant to first-line therapies. S: SUBJECTIVE
Oropharyngeal Candidiasis The patient may complain of white patches on the tongue and oral mucosa, smooth red areas on the dorsal tongue, burning or painful areas in the mouth, a bad or unusual taste, sensitivity to spicy foods, or decreased appetite. Esophageal Candidiasis The patient complains of difficulty or pain with swallowing, or the sensation that food is "sticking" in the retrosternal chest. Weight loss is common, and nausea and vomiting may occur. Fever is not common with candidal esophagitis and suggests another cause.
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Article 3: Candidiasis: Oral, Esophageal, Vulvovaginal
O: OBJECTIVE Patients presenting with oral candidiasis may be totally asymptomatic, so it is important to inspect the oral cavity thoroughly. Lesions can occur anywhere on the hard and soft palates, under the tongue, on the buccal mucosa or gums, or in the posterior pharynx. Pseudomembranous oral candidiasis appears as creamy white, curdlike plaques on the buccal mucosa, tongue, and other mucosal surfaces. Typically, the plaques can be wiped away, leaving a red or bleeding underlying surface. Lesions may be as small as 1-2 mm, or may form extensive plaques that cover the entire hard palate. Erythematous oral candidiasis presents as 1 or more flat, red, subtle lesions on the dorsal surface of the tongue or the hard or soft palate. The dorsum of the tongue may show loss of filiform papillae. Angular cheilitis causes fissuring and redness at 1 or both corners of the mouth and may appear alone or in conjunction with another form of oral Candida infection. Patients with esophageal candidiasis usually have oral thrush and often have weight loss. A: ASSESSMENT A partial differential diagnosis for the 2 conditions is as follows:
Oropharyngeal Candidiasis o Oral hairy leukoplakia o Burn o Bacterial gingivitis o Periodontitis Esophageal Candidiasis o Cytomegalovirus (CMV) o Herpes simplex virus (HSV) o Aphthous ulceration
P: PLAN Diagnostic Evaluation: Oropharyngeal candidiasis Clinical examination alone usually is diagnostic. If the diagnosis is unclear, organisms may be detected on smear or culture if necessary. o Potassium hydroxide (KOH) preparation of a smear collected by gentle scraping of the affected area with a wooden
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tongue depressor. Visible hyphae or blastospheres on KOH mount indicate Candida infection. o Culture is diagnostic and may detect non- albicans species in cases resistant to first-line therapies. Sensitivities may also be needed in such cases to diagnose azole-resistant infections. Esophageal candidiasis A presumptive diagnosis can usually be made with a recent onset of dysphagia, especially in the presence of thrush, and empiric antifungal therapy may be started. If the patient fails to improve clinically after 3-7 days of therapy, endoscopy should be performed for a definitive diagnosis.
TREATMENT Treatment of oropharyngeal candidiasis o Oral therapy is convenient and very effective as first-line treatment. Note that azole antifungal drugs are not recommended for use during pregnancy. Fluconazole 100 mg once daily for 7-14 days o Alternative topical therapy is less expensive, safe for use during pregnancy, and effective for mild to moderate disease. Such therapies include: Clotrimazole troches dissolved in the mouth 5 times per day for 2 weeks Nystatin oral suspension 5 mL "swish and swallow" 4 times daily for 2 weeks o Other alternatives include the following: Itraconazole oral solution 200 mg once daily for 7-14 days o Itraconazole capsules and ketoconazole 200 mg once daily for 7-14 days (less effective) o These agents present a greater risk of drug interactions and hepatotoxicity than do fluconazole or topical treatments. Treatment of esophageal candidiasis o Fluconazole 200 mg as an initial dose, then 100 mg by mouth once daily for 14 days. Intravenous therapy can be given if the patient is unable to swallow pills. o Itraconazole oral suspension 200 mg once daily for 14 days o Alternative (less effective) treatments include itraconazole capsules 200 mg once daily or ketoconazole 200 mg once daily for 14 days Treatment of refractory candidiasis Oral or esophageal candidiasis that does not improve after at least 7-14 days of azole antifungal therapy can be considered refractory
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to treatment. The primary risk factors for development of refractory candidiasis are CD4 counts <50 cells/L and prolonged, chronic antifungal therapy (especially with azoles). In such cases, it is important to confirm the diagnosis of candidiasis. As noted previously, other infections such as HSV, CMV, and aphthous ulcerations can cause similar symptoms. Once refractory candidiasis is confirmed, several treatment options are available, including the following: o Patients with candidiasis refractory to low-dose fluconazole (100-200 mg once daily) may respond to higher dosages (400-800 mg once daily) o Itraconazole oral suspension 200 mg once daily o Voriconazole 200 mg intravenously or by mouth twice daily (Voriconazole therapy is contraindicated for patients taking protease inhibitors because of significant drug interactions.) o Amphotericin B 100 mg/mL oral suspension, 1 mL 4 times daily o Amphotericin B 0.5 mg/kg/d intravenously, or amphotericin liposomal complex 3-5 mg/kg/d intravenously o Caspofungin 50 mg intravenously once daily The choice of treatment depends upon the patient's preferences and tolerance, convenience, availability of medications, and the provider's experience. Consult with an HIV or infectious disease expert for advice about treatment regimens. Maintenance therapy Use caution when considering chronic maintenance therapy, because it has been associated with refractory and azole-resistant candidiasis, as noted above. Fluconazole 100-200 mg daily or weekly, or itraconazole solution, can be effective for patients who have had multiple recurrences of oral or esophageal disease (azole sensitive). Patients who achieve immunologic and virologic responses to antiretroviral therapy may be able to discontinue maintenance therapy. Patient Education

Patients should maintain good oral hygiene by brushing teeth after each meal. A soft toothbrush should be used to avoid mouth trauma. Advise patients to rinse the mouth of all food before using lozenges or liquid medications. Tell patients to avoid foods or liquids that are very hot in temperature or very spicy.
34

Patients who have candidiasis under a denture or partial denture should remove the prosthesis before using topical agents such as clotrimazole or nystatin. At bedtime, the prosthesis should be placed in a chlorhexidine solution until reinserting it into the mouth. Pregnant women or women who may become pregnant should avoid azole drugs (eg, fluconazole, itraconazole, voriconazole) during pregnancy because they can cause skeletal and craniofacial abnormalities in infants.
REFERENCES U.S. Public Health Service, Infectious Diseases Society of America.Guidelines for preventing opportunistic infections among HIV-infected persons--2002 . MMWR Recomm Rep. 2002 Jun 14;51(RR08);1-46. Available online at aidsinfo.nih.gov/Guidelines/. Accessed May 19, 2006. Centers for Disease Control and Prevention, National Institutes of Health, HIV Medicine Association/Infectious Diseases Society of America. Treating Opportunistic Infections Among HIVInfected Adults and Adolescents . MMWR Recomm Rep. 2004 Dec 17; 53(RR15);1-112. Available online at aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?GuidelineID=14. Accessed May 19, 2006. Fichtenbaum CJ. Candidiasis . In: Dolin R, Masur H, Saag MS, eds. AIDS Therapy, 2nd ed . Philadelphia: Churchill Livingstone; 2003:531-542. Mnkemller KE, Wilcox CM. Diseases of the Esophagus, Stomach, and Bowel . In: Dolin R, Masur H, Saag MS, eds. AIDS Therapy, 2nd ed . Philadelphia: Churchill Livingstone; 2003:885-901. Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis . Clin Infect Dis. 2004 Jan 15;38(2):161-89.
CANDIDIASIS VULVOVAGINAL BACKGROUND Vulvovaginal candidiasis is a yeast infection caused by several types of Candida , typically Candida albicans . This disease is common in all women, but may occur more frequently and more severely in immunocompromised women. Although refractory vaginal Candida infections by themselves should not be considered indicators of HIV infection, they may be the first clinical manifestation of HIV infection, and can occur early in the course of disease (at CD4 counts >500 cells/L). The frequency of vaginal candidiasis tends to increase as CD4 counts decrease; this may, however, be due in part to increased antibiotic use among women with advanced HIV infection. Risk factors for candidiasis include diabetes mellitus and the use of oral contraceptives, corticosteroids, or antibiotics. S: SUBJECTIVE
35

The patient may complain of itching, burning, or swelling of the labia and vulva; a thick white or yellowish vaginal discharge; painful intercourse; and pain and burning on urination. The most important elements in the history include:

Type and duration of symptoms Previous vaginal yeast infection Oral contraceptive use Recent or ongoing broad-spectrum antibiotic therapy Recent corticosteroid therapy Sexual exposures (to evaluate for sexually transmitted infections) Diabetes history Cushing syndrome Obesity Hypothyroidism Pregnancy Use of douches, vaginal deodorants, or bath additives
O: OBJECTIVE A focused physical examination of the external genitalia may reveal inflammation of the vulva with evidence of discharge on the labial folds and vaginal opening. Speculum examination usually reveals a thick, white discharge with plaques adhering to the vaginal walls and cervix. Bimanual examination should not elicit pain or tenderness and otherwise should be normal. A: ASSESSMENT Rule out other causes of vaginal discharge and pruritus:

Bacterial vaginosis Atrophic vaginitis Pediculosis Chemical or mechanical causes
Trichomoniasis Gonorrhea, chlamydia, and other sexually transmitted infections Scabies Pediculosis
P: PLAN Diagnostic Evaluation A presumptive diagnosis is made on the basis of the clinical presentation and potassium hydroxide (KOH) preparation:
36

Perform microscopic examination of a KOH preparation of vaginal secretions. This exam usually reveals pseudohyphae and Candida spores (presumptive diagnosis). Definitive diagnosis is rarely needed, but may be made by a culture of vaginal secretions. In the presence of urinary tract symptoms (beyond external vulvar burning), perform urinalysis, culture, or both on a cleancatch urine specimen. Consider testing for gonorrhea and chlamydia in patients with a history of possible sexual exposure.
TREATMENT
Uncomplicated infections
Topical medications
o
Prescribe topical vaginal antifungal agents in the form of cream or suppositories: butoconazole, clotrimazole, miconazole, nystatin, terconazole, tioconazole. Treat for 3-7 days and offer refills depending on the time to the next scheduled clinic visit. The creams may also be used on the vulva for pruritus. Nystatin vaginal pastilles 100,000 units; insert 1 daily for 14 days
Note that the mineral-oil base in topical vaginal antifungal preparations may erode the latex in condoms, diaphragms, and dental dams. Advise the patient to use alternative methods to prevent HIV transmission or conception, or to discontinue intercourse while using these medications. Nonlatex condoms (plastic and polyethylene only) or "female" condoms (polyurethane) can be used.
Oral medications
o o
Fluconazole 150 mg orally, 1 dose (see "Treatment notes" below) Itraconazole 200 mg orally twice daily for 1 day, or 200 mg orally once daily for 3 days (see Treatment notes below)
Complicated infections
Severe or recurrent candidiasis

Severe or recurrent candidiasis is defined as 4 or more episodes within 1 year. Consider the following treatments:
o o
Topical therapy as above, for 7-14 days Fluconazole 150 mg orally every 3 days for 3 doses (see "Treatment notes" below)
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For severe cases that recur repeatedly, secondary prophylaxis can be considered, eg, clotrimazole vaginal suppository (500 mg once weekly) or oral fluconazole (100-200 mg weekly).
Non-albicans candidiasis
o o o
Non-fluconazole azole for 10-14 days (see "Treatment notes" below) Boric acid 600 mg intravaginal gelatin capsules once daily for 2 weeks for refractory cases Consult with a specialist
Treatment notes
Systemic azole drugs are not recommended during pregnancy, and women taking azoles should use effective contraception. Topical azoles are recommended or the treatment of pregnant women. Itraconazole interacts with some antiretroviral medications; check for adverse drug interactions before prescribing. Itraconazole should not be used by pregnant women or women considering pregnancy. Resistance to azole medications may develop, especially with prolonged use of oral agents. Avoid ketoconazole: Case reports have associated ketoconazole with a risk of fulminant hepatitis (1 in 12,000 courses of treatment with oral ketoconazole). Experts agree that the risks may outweigh the benefits in women with vulvovaginal candidiasis. Ketoconazole also interacts with many other drugs, including some antiretroviral drugs.
Patient Education
Advise women to wash external genitals daily with a fresh washcloth or water-soaked cotton balls and to wipe the vulva and perirectal area from front to back after toileting. Women should not use baby wipes on inflamed vulval tissue because they may increase irritation. Women should avoid the use of perfumed soaps, bubble baths, feminine hygiene or vaginal deodorant products, and bath powders. Advise women not to douche. Women should wear cotton underwear and avoid tight, constrictive clothing, particularly pantyhose. If women are prescribed medication for vaginal candidiasis, they should take the medication exactly as prescribed and finish the medicine even during a menstrual period. Women who continue to have symptoms, can purchase Monistat or Gyne-Lotrimin medication over the counter. Advise patients to start using these as soon as symptoms come back,
38

and to call the clinic if symptoms get worse while they are taking these medicines. Women taking fluconazole or ketoconazole must avoid pregnancy. Some birth defects have been reported. The mineral-oil base in topical vaginal antifungal preparations may erode the latex in condoms, diaphragms, and dental dams. Advise patients to use alternative methods to prevent HIV transmission or conception or to discontinue intercourse while using these medications. Nonlatex condoms (plastic and polyethylene only) or "female" condoms (polyurethane) can be used. Sex toys, douche nozzles, diaphragms, cervical caps, and other items can reinfect patients if not properly cleaned and thoroughly dried after use. Some studies have suggested that eating yogurt with live cultures (check labels) can reduce the occurrence of vaginal yeast infections.
REFERENCES Abularach S, Anderson J. Gynecologic Problems . In: Anderson JR, ed. A Guide to the Clinical Management of Women with HIV. Rockville, MD: Health Resources and Services Administration, HIV/AIDS Bureau; 2005. Available online at hab.hrsa.gov/publications/womencare05/. Accessed May 19, 2006. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006 . MMWR 2006;55(No. RR-11):1-100. U.S. Public Health Service, Infectious Diseases Society of America.Guidelines for preventing opportunistic infections among HIV-infected persons--2002 . MMWR Recomm Rep. 2002 Jun 14;51(RR08);1-46. Available online at aidsinfo.nih.gov/Guidelines/. Accessed May 19, 2006. Cohn SE, Clark RA. Sexually transmitted diseases, HIV, and AIDS in women . In: The Medical Clinics of North America, Vol. 87; 2003:971-995. Hatcher RA, Stewart FH, Trussell J, et al. Contraceptive Technology, 15th ed . New York: Ardent Media; 1999:123-5. Sande MA, Eliopoulos GM, Moellering RC, et al. The Sanford Guide to HIV/AIDS Therapy, 14th ed . Hyde Park, VT: Antimicrobial Therapy, Inc.; 2005. Spence D. Candidiasis (vulvovaginal) . Clin Evid. 2004 Dec;(12):2493-511.
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CANDIDAL BALANITIS
SOURCE: http://www.bccdc.ca/NR/rdonlyres/8C714F46-07E7-40A5-AB4C-7FB290EF2E6C/0/STI_DS T_Noncertified_candidal_balanitis_20100408.pdf AUTHOR(s): British Columbia Centre for Disease Control (BCCDC) - Sexually Transmitted Infections (STI) / HIV Division Reproductive Health LAST UPDATED: April 1, 2010
DEFINITION Balanitis refers to inflammation of the glans, while posthitis refers to inflammation of the foreskin. Inflammation of both of these is known as balanoposthitis. The most common cause of balanitis is Candida
albicans.
POTENTIAL CAUSES
Candida albicans is the most common cause of yeast infections.

PREDISPOSING RISK FACTORS uncircumcised penis usually not considered sexually transmitted sometimes occurs after intercourse with female partner who has vaginal yeast antibiotic use corticosteroid use immunocompromised poorly controlled diabetes
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Article 4: Candidal Balanitis
TYPICAL FINDINGS Sexual Health History may or may not have had sexual contact recent antibiotic and/or corticosteroid use diabetic
Physical Assessment Presence of rash to glans penis that may appear dry, as raised red dots or bumps, or excoriated Diagnostic Tests Diagnosis based on clinical findings. TREATMENT OF CHOICE For yeast balanitis or external fungal rash: Clotrimazole topical cream applied bid for 10-14 days, or Miconazole topical cream applied bid for 10-14 days Consult with physician or NP if client is also receiving anticoagulants.
Note: Miconazole use is contraindicated with some anticoagulants.
ALTERNATE TREATMENT Refer to physician/NP for oral therapy: Fluconazole 150 mg tablet PO stat PARTNER COUNSELLING AND REFERRAL Suggest assessment of female partners for vaginal yeast infection and possible treatment. POTENTIAL COMPLICATIONS Chronic yeast balanitis. CLIENT EDUCATION AND FOLLOW-UP Counsel client: female partners may require assessment and treatment for vaginal yeast infection regarding the proper use and side effects of medication
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Article 4: Candidal Balanitis
oral antibiotics, corticosteroid use, and/or poorly controlled diabetes, can all cause yeast infections treatment is most effective if the cream is applied for at least 10 days even if symptoms subside sooner.
CONSULTATION AND/OR REFERRAL Consult or refer to physician/NP for the following: client is taking anticoagulants if oral anti-fungal therapy is indicated if symptoms persist after completion of treatment
REFERENCES Habif, T. (1996). Clinical Dermatology: A color guide to diagnosis and therapy. 3rd edition. Mosby. Holmes, K., Sparling, P., Stamm, W., Piot, P., Wasserheit, J., Corey, L., Cohen, M., Watts, H. (2008). Sexually transmitted disease (4th ed). Toronto, ON: McGraw Hill Medical. McMillan, A., Young, H., Ogilvie, M., Scott, G. (2002). Clinical Practice in Sexually Transmissible Infections. Saunders: London.
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MUCOCUTANEUS CANDIDIASIS AND HIV

SOURCE: http://hivinsite.ucsf.edu/InSite?page=kb-05-02-03#S2X AUTHOR: Carl J. Fichtenbaum, MD, University of Cincinnati; Judith A. Aberg, MD, New York University LAST UPDATED: February 2006
Introduction Mucocutaneous candidiasis occurs in 3 forms in persons with HIV infection: oropharyngeal, esophageal, and vulvovaginal disease. Oropharyngeal candidiasis (OPC) was among the initial manifestations of HIV-induced immunodeficiency to be recognized (1,2) and typically affects the majority of persons with advanced untreated HIV infection. Presenting months or years before more severe opportunistic illnesses, OPC may be a sentinel event indicating the presence or progression of HIV disease.(3-5) Although usually not associated with severe morbidity, OPC can be clinically significant. Severe OPC can interfere with the administration of medications and adequate nutritional intake, and may spread to the esophagus.(6) Esophageal candidiasis remains one of the most common opportunistic infections in countries where combination antiretroviral therapy (ART) is a routine part of the standard of care.(7) Vulvovaginal candidiasis is an important concern for women with HIV infection, although the relationship of vulvovaginal candidiasis to HIV infection remains unclear.(8) In resourcepoor nations, mucocutaneous candidiasis is a formidable problem.(9,10) Despite the frequency of mucosal disease, disseminated or invasive infections with Candida and related yeasts are surprisingly uncommon. Microbiology and Epidemiology Yeasts are fungi that grow as single cells and reproduce by budding. They are distinguished from one another on the basis of the presence or absence of capsules, their size and shape, the mechanism of daughter formation, the formation of true hyphae or pseudohyphae, and the presence or absence of sexual spores, along with physiologic data from biochemical testing. Candida albicans is the predominant causative agent of all forms of mucocutaneous candidiasis. Less frequently, C glabrata, C parapsilosis, C tropicalis, C krusei, and several other species may cause disease. C dubliniensis, a species that is phenotypically similar to C albicans, may cause approximately 15% of infections previously ascribed to C albicans.(11-14)
Candida are normal inhabitants of the human gastrointestinal (GI) tract and
may be recovered from up to one third of the mouths of normal individuals and two thirds of those with advanced HIV disease.(15,16) Oral colonization with inherently drug-resistant organisms is more common in advanced HIV infection (CD4 lymphocyte counts <50 cells/L).(16) Although vaginal
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Article 5: Mucocutaneus Candidiasis and HIV colonization is more prevalent among HIV-infected women compared with HIV-negative women, no association of colonization rate with CD4 counts is apparent.(17) The majority of disease is caused by organisms that are part of the normal flora of an individual, although rare cases of person-to-person transmission have been documented.(18) The individual Candida strains affecting persons with HIV infection are not different from those in other immunosuppressed hosts.(19) C dubliniensis is more commonly identified in HIV-infected persons, though it is currently indistinguishable from C albicans in its clinical presentation.(11-13) There are no detectable differences in the virulence of strains isolated from HIVinfected or HIV-uninfected persons. Recurrent disease can result from the same or from different species or strains of Candida.(20-23) The emergence of different strains or species is more likely in persons with lower CD4 lymphocyte counts and exposure to antifungal therapy.(19) Oropharyngeal and vulvovaginal disease are the most common forms of mucocutaneous candidiasis. Up to 90% of persons with advanced untreated HIV infection develop OPC, with 60% having at least 1 episode per year with frequent recurrences (50-60%).(16,21,24-32) Esophageal candidiasis occurs less frequently (10-20%) but is the leading cause of esophageal disease.(3335) Vaginal candidiasis has been noted in 27-60% of women, similar to the rates of oropharyngeal disease.(36-38) However, the incidence appears to be similar in HIV-infected and HIV-uninfected women.(8) Of note, 75% of all women of childbearing age develop vaginal candidiasis and 40% will have a second occurrence. Few women (<5%) experience frequent recurrences (defined as >=4 infections in a 12-month period). The use of combination ART results in a significant decline in the incidence of a number of opportunistic illnesses (eg, Pneumocystis jirovecipneumonia and cytomegalovirus).(39-41) Thus, in resource-rich nations, the incidence of mucocutaneous candidiasis has declined precipitously. For example, a significant difference has been found in the incidence of recurrent OPC in patients treated with protease inhibitors compared with those not treated with protease inhibitors (7% vs 36%).(42) Similarly, a decline in the incidence of OPC from 30% to 4% over a 1-year period was reported in persons on ART.(43) More frequent use of antifungal medications for secondary prevention also may have reduced the prevalence of mucocutaneous disease. A number of factors are important in the development of mucocutaneous candidiasis.(44) The level of immunosuppression is paramount.(45) Other host factors important in the defense of Candida infections include blood group secretor status (such as presence or absence of specific Lewis antigens), salivary flow rates, condition of the epithelial barrier, antimicrobial constituents of saliva, presence of normal bacterial flora, and local immunity.(27,46) Several studies suggest an impairment in a number of antiCandida host defense mechanisms in persons with HIV infection.(27,29,30) Higher levels of HIV-1 RNA in the plasma also have been associated with increased rates of mucocutaneous candidiasis and colonization with Candida.(42,47) Of note, the correlation between the level of immunosuppression and vaginal candidiasis may not be as strong. In a
44

Article 5: Mucocutaneus Candidiasis and HIV cross-sectional study of 833 HIV-infected and 427 HIV-uninfected women, the annual incidence of vaginal candidiasis in the 2 groups was similar (9%).(38) Clinical Presentation Symptoms of OPC may include burning pain, altered taste sensation, and difficulty swallowing liquids and solids. Many patients are asymptomatic. Most persons with OPC present with pseudomembranous candidiasis or thrush (white plaques on the buccal mucosa, gums, or tongue) and less commonly with acute atrophic candidiasis (erythematous mucosa) or chronic hyperplastic candidiasis (leukoplakia, distinct from "hairy leukoplakia"; see chapter on Oral Manifestations) involving the tongue, or angular cheilitis (inflammation and cracking at the corners of the mouth). Esophageal candidiasis usually is accompanied by the presence of OPC. Typically, dysphagia and odynophagia are described. In as many as 40% of patients with OPC, esophageal involvement may be asymptomatic.(6) Occasionally, esophageal disease may occur in the absence of clinically detectable oropharyngeal disease. Vulvovaginal candidiasis generally presents with marked itching, watery to curdlike discharge, vaginal erythema with adherent white discharge, dyspareunia, external dysuria, erythema, and swelling of labia and vulva with discrete pustulopapular peripheral lesions. The cervix usually appears normal. Symptoms typically exacerbate the week preceding menses with some relief once menstrual flow begins. Vaginal candidiasis frequently is associated with pregnancy, high-estrogen oral contraceptives, uncontrolled diabetes mellitus, tight-fitting clothes, antibiotic therapy, dietary factors, intestinal colonization, and sexually transmitted disease. Specific additional risk factors for recurrent vulvovaginal candidiasis have not been identified.(48) Female-to-male transmission remains questionable, although male sexual partners may experience a transient rash, erythema, pruritus, or burning sensation of the penis minutes to hours after unprotected sexual intercourse. Occasionally, Candida balanitis may occur. Diagnosis The diagnosis of OPC usually is made by its characteristic clinical appearance; recovery of an organism is not required. Oropharyngeal cultures often demonstrate Candida species, but alone are not diagnostic because colonization is common.(24) The diagnosis of OPC can be confirmed by examining a 10% potassium hydroxide (KOH) slide preparation of a scraping from an active lesion. Pseudohyphae and budding yeast are characteristic findings. The appearance of the lesion and presence of yeast forms on microscopic examination of the oropharynx are sufficient to confirm the diagnosis. A KOH preparation is not mandatory for diagnosing OPC. A presumptive diagnosis of OPC can be made by visual detection of characteristic lesions with resolution of those lesions in response to antifungal therapy. Culture usually is not necessary unless the lesions fail to
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Article 5: Mucocutaneus Candidiasis and HIV clear with appropriate antifungal therapy. In patients with poorly responsive OPC, a culture should be obtained to look for inherently drug-resistant yeast or those that respond poorly to certain azoles (eg, C krusei or C glabrata). Clinicians should note that many microbiology laboratories report yeast cultures as either C albicans or non-albicans species based upon the germ tube test, and further characterization requires making a specific request. Biopsy of oral lesions rarely is helpful or indicated for the diagnosis of oral candidiasis. A presumptive diagnosis of Candida esophagitis can be made in a patient with dysphagia and/or odynophagia who has OPC. Barium swallow or upper GI endoscopy can confirm a suspicion of esophageal involvement. These studies are not uniformly required, however, unless a patient fails to improve with appropriate systemic antifungal therapy.(35) If esophageal symptoms in a patient with OPC do not resolve despite resolution of the oral lesions, endoscopy is indicated to exclude other causes of esophagitis (eg, cytomegalovirus, herpes simplex virus, aphthous ulcers) in persons with HIV infection. The diagnosis of Candida esophagitis is confirmed by the presence of yeast forms on histologic examination of esophageal lesions. Cultures to look for drug-resistant yeast are warranted for patients who require endoscopy. Barium swallow rarely is indicated in HIV-infected patients with esophageal disease because it usually is not possible to determine the cause of an abnormality by its radiologic appearance alone. The diagnosis of Candida vulvovaginitis is made by the presence of a characteristic clinical appearance and observation of yeast forms on microscopic examination. A KOH preparation of the vaginal discharge should be made to confirm the diagnosis of candidiasis and to differentiate from a number of other conditions that can be similar in appearance (eg, trichomoniasis). Because yeast are normal inhabitants of the vaginal mucosa, routine fungal cultures rarely are helpful when the KOH preparation is negative. A fungal culture should be obtained if a patient fails to respond to standard antifungal therapy. Antifungal susceptibility testing has improved over the past few years but remains problematic. In 2002, the National Committee on Clinical Laboratory Standards (NCCLS) published standardized methods and definitions for in vitro susceptibilities to selected agents (Table 1).(49,50) The most common methods for in vitro testing are the macrotube and microtiter broth dilution assays. Alternative methods such as agar-based assays and flow cytometry are under evaluation.(51) In vitro susceptibilities should not be used routinely to guide the choice of antifungal agents because the correlation between clinical response and susceptibility testing is not clear. Despite the technical limitations, a number of studies have documented that in vitro resistance to antifungal medications is common.(16,52-64) The incidence of resistance varies widely in these studies. Overall, the rates of fluconazole resistance vary from 5% to 56%.(16,52-57) The rates of ketoconazole and itraconazole resistance have been reported less frequently but vary from 0% to 25%.(58-60) Amphotericin B resistance is extremely uncommon but has been reported.(64) Resistance to newer agents including echinocandins and triazoles (eg, voriconazole and posaconazole) is less common but has been
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Article 5: Mucocutaneus Candidiasis and HIV documented.(65,66) Much of the variance in the rates of in vitro resistance can be explained by several factors: differences in the level of host immunosuppression, prior exposure to antifungal agents, the design of the study (longitudinal vs cross-sectional), the prevalence of nonalbicans species of yeast, and differences in the in vitro methods used. Several mechanisms may contribute to in vitro resistance to antifungals. Some yeasts have single-drug resistance, whereas others are multidrug resistant. Azole resistance has been demonstrated in yeasts that contain alterations in the enzymes that were the target of azole action or were involved in ergosterol biosynthesis. The cytochrome P450-dependent 14alpha-sterol demethylase (P450DM) and the delta5,6sterol desaturase are enzymes that, when altered, result in azole resistance.(67,68) Reduced cell permeability is another mechanism of azole resistance.(69) Finally, active efflux of drug also has been observed.(70) The prevalence of these mechanisms, however, is unknown. Further, it is not clear whether certain mechanisms of resistance may be overcome by increasing the dosage of the drug.
Table 1. Definition of In Vitro Resistance for Candida Species Range of Minimum Inhibitory Concentrations (MICs) (g/mL) Antifungal Agent Susceptible Susceptible-dose dependent Resistant Itraconazole Fluconazole Amphotericin B <=0.125 <=8.0 <=1.0 0.25-0.5 16-32 >=1.0 >64 >=2.0
Adapted from the proposed and tentative National Committee on Clinical Laboratory Standards (NCCLS) standard definitions for antifungal susceptibilities using microbroth or macrotube dilution methodology.(a)
Therapy A wide variety of agents are effective for the treatment of candidiasis (Table 2). Important factors that determine clinical response, besides the choice of antifungal agent, include the extent and severity of disease, patient adherence, and the pharmacokinetic properties of the drug. Treatment of OPC and vaginal candidiasis is relatively simple, with most types responding to therapy. Overall, randomized studies show little difference between topical and systemic therapy. Mild OPC or vulvovaginal disease often can be treated with topical therapy. Moderate and severe episodes typically require systemic therapy. Esophagitis always requires systemic therapy.
Table 2. Therapeutic Options for Mucosal Candidiasis Medication Adult Dosage Important Toxicities
Oropharyngeal Candidiasis
Clotrimazole troches Nystatin suspension Ketoconazole 10 mg 4-5/day x 7-14 days 100,000 units/cc 5 cc QID x 7-14 days 200 mg/day x 7-14 days Altered taste, GI upset GI upset GI upset, hepatitis,
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Article 5: Mucocutaneus Candidiasis and HIV
endocrine effects Itraconazole Fluconazole 100-200 mg/day x 7-14 days 100-200 mg/day x 7-14 days GI upset, hepatitis GI upset, hepatitis
Esophageal Candidiasis
Fluconazole* Ketoconazole Itraconazole Micafungin Caspofungin 100-400 mg/day x 14-21 days GI upset, hepatitis 400 mg/day x 14-21 days 200 mg/day x 14-21 days 150 mg/day x 14-21 days 50 mg/day x 7-21 days 6 mg/kg IV Q 12 hours x 2 doses then 4 mg/kg IV Q12 hours Or Weight <40 kg: 100 mg/day orally x 14-21 days Weight >40 kg: 200 mg/day orally x 14-21 days 0.5 mg/kg/day IV x 14-21 days 3 mg/kg/day IV x 14-21 days GI upset, hepatitis, endocrine effects GI upset, hepatitis GI upset, hepatitis, injection site reactions Fever, flushing, GI upset
Voriconazole
GI upset, visual disturbances, hepatitis
Amphotericin B deoxycholate Liposomal amphotericin B
Renal failure, electrolyte losses, fever, chills, sweats Fever, renal failure, electrolyte losses
Vulvovaginal Candidiasis #
Fluconazole Butoconazole 2% cream 2% cream Clotrimazole Suppositories Suppositories 1% cream 1% cream Miconazole Suppositories 2% cream 4% cream Nystatin tablets

150 mg once
Minimal GI upset
5 g at bedtime x 3 days 5 g once
Local irritation Local irritation
100 mg x 7 days 200 mg x 3 days 5 g BID x 3 days 5 g/day x 7 days
Local irritation Local irritation Local irritation Local irritation
100 mg/day x 7 days 5 g/day x 7 days 5 g at bedtime x 3 days 100,000 unit tablet x 14 days 4.6 g single dose
Local irritation Local irritation Local irritation Local irritation Local irritation
Tioconazole 6.5% cream Terconazole 0.4% cream
5 g/day x 7 days
Local irritation
48

0.8% cream 80-mg suppositories
5 g/day x 3 days 1/day x 3 days
Local irritation Local irritation
* Drug of choice # Nonprescription alternatives available for most topical drugs with treatment for 3 to 7 days. Presence of vulvar disease requires additional use of cream directly on rash for 3 to 7 days. BID = 2 times per day IV = intravenously Q = every QID = 4 times per day
Classes of antifungal agents include polyenes (nystatin and amphotericin B), which bind to ergosterol in the fungal cell membrane and induce osmotic instability and loss of membrane integrity; azoles, including the imidazoles (clotrimazole) and triazoles (ketoconazole, itraconazole, fluconazole, voriconazole, ravuconazole, and posaconazole), which inhibit fungal cytochrome P450-dependent enzymes, resulting in the impairment of ergosterol biosynthesis and depletion of ergosterol from the fungal cell membrane; pyrimidine synthesis inhibitors, including 5-fluorocytosine (flucytosine), which inhibits DNA and RNA synthesis in fungal organisms; and the echinocandins (caspofungin, micafungin and anidulafungin), cyclic lipopeptides that inhibit beta-1:3 glucan synthase, an enzyme involved in fungal wall cell biosynthesis. Nystatin is used in a topical preparation. The oral form is not absorbed and has minimal side effects other than dysgeusia. Flucytosine is available as a tablet and is associated with such side effects as nausea, vomiting, diarrhea, GI bleeding, renal insufficiency, hepatitis, thrombocytopenia, anemia, and leukopenia. Although the manufacturer recommends maintaining flucytosine levels between 25 and 100 g/mL, most clinicians monitor laboratory parameters (complete blood count, liver function tests, and renal function tests) and the patient for adverse effects. Clotrimazole is available as a spray, solution, and troche for oral use. Clotrimazole has few side effects, and is absorbed from the GI tract poorly. Ketoconazole is available as a tablet or cream. Oral absorption is enhanced when the gastric pH is <4.0. Achlorhydria has been documented in HIV-infected patients and, when present, may interfere with ketoconazole absorption.(71) Itraconazole is available in a cyclodextrin oral solution, capsule, and parenteral form. The suspension and intravenous formulations have enhanced bioavailability compared with the capsule formulation. Absorption is improved when itraconazole is taken after a meal. Fluconazole, the first triazole compound released in the United States, is absorbed more completely than itraconazole or ketoconazole because absorption is not dependent on gastric acidity or food intake. Fluconazole is available in suspension, tablet, and parenteral form. In general, the side effects of ketoconazole, itraconazole, fluconazole, posaconazole, and voriconazole are similar, the more common being headache, dyspepsia, diarrhea, nausea, vomiting, hepatitis, and skin rash.(72) Voriconazole can cause reversible mild abnormal vision.(73) Prolonged administration of azoles may require surveillance of liver enzymes to monitor for hepatotoxicity. Significant drug interactions with each of these medications are provided in Table 3. The echinocandins are available only in
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Article 5: Mucocutaneus Candidiasis and HIV parenteral forms. Caspofungin and micafungin are approved by the U.S. Food and Drug Administration (FDA) for the treatment of esophageal candidiasis. Adverse events including fever, nausea, infused-vein complications, and vomiting typically are mild.(74) Most antifungal treatment studies for mucocutaneous candidiasis are difficult to interpret, given the small numbers of patients, heterogeneous populations, short follow-up, and nonblinded design. Specifically, no study has stratified patients by CD4+ lymphocyte count. This point is important because persons with low CD4+ lymphocyte counts may respond more slowly to treatment, have lower rates of fungal eradication, and have higher relapse rates than persons with less advanced disease. No treatment trials for vulvovaginal candidiasis in women with HIV infection have been published. Recommendations for the treatment of vulvovaginal disease are made based on data from the non-HIV-infected population.
Table 3. Important Drug Interactions with Selected Antifungal Medications Interacting Drug Anticoagulants, oral Antihistamines (terfenadine, astemizole) Carbamazepine Cisapride Contraceptives, oral Cyclosporine A (CSA)/tacrolimus Didanosine Digoxin HMG-CoA inhibitors Sulfonylureas Isoniazid H2 blockers/proton pump inhibitors Phenytoin Rifabutin Rifampin Theophylline Abbreviations F = fluconazole I = itraconazole K = ketoconazole V = voriconazole Antifungal F, K,V I, F, K,V I,V I, F, K,V I, F, K I, F, K,V I, K I,V I, F, K,V F, K I, F, K,V I, K I, F, K,V F, V I, F, K,V I, F, K,V Effect and Manifestations Increase anticoagulant levels (prolonged PT, bleeding) Increase antihistamine levels (ventricular arrhythmias) Decrease I,V levels (decreased efficacy); Increase carbamazepine Increase cisapride levels (ventricular arrhythmias) Decrease efficacy of oral contraceptives (pregnancy) Increase CSA/tacrolimus level (CSA/tacrolimus toxicity) Complex interaction with decreased levels of involved drugs Increase digoxin levels (digitalis toxicity) Increase HMG-CoA inhibitor levels (rhabdomyolysis) Increase oral hypoglycemic effect (hypoglycemia) Decrease I, F, K levels (decreased efficacy) Increase in V levels Decrease I, K levels (decreased efficacy) Complex (Decrease I, K levels // V, F increase phenytoin levels) Increase rifabutin levels (uveitis) Decrease I, F, K levels (decreased efficacy) Increase theophylline levels (toxicity)
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Article 5: Mucocutaneus Candidiasis and HIV Most of the published controlled trials for the treatment of oral and esophageal candidiasis are listed in Table 4. Response rates range from 34% to 100% in studies of treatment for oral and esophageal disease.(31,75-82) In clinical experience, the response rates to standard antifungal treatments are on the order of 75-95%. There are few significant differences in response rates between topical and systemic therapies or among the different systemic therapies for OPC. Thus, it is reasonable to conclude that clotrimazole, ketoconazole, fluconazole, and itraconazole probably are equivalent in the acute treatment of most cases of OPC. The treatment of esophageal candidiasis has not been studied so well as the treatment of OPC. Most experts recommend systemic therapy because of the significant morbidity of esophageal candidiasis and the absence of evidence supporting the use of topical therapy. Response rates to systemic therapies generally are quite good. Fluconazole has proved to be more effective than ketoconazole in one trial.(80) There have been no comparative studies of itraconazole in tablet or solution vs fluconazole. Itraconazole solution probably is equivalent to fluconazole for treating esophageal candidiasis.
Table 4. Clinical Trials for the Treatment of Oral and Esophageal Candidiasis in Persons with HIV Medication Clinical Response Mycologic Response Relapse Rate Reference
Oral Candidiasis
Fluconazole 100 mg/d Fluconazole 100 mg/d Fluconazole 50 mg/d Fluconazole 200 mg/d Fluconazole 100 mg/d Fluconazole 100 mg/d Clotrimazole 10 mg 5x/d Clotrimazole 10 mg 5x/d Ketoconazole 200 mg/d Ketoconazole 200 mg BID Ketoconazole 200 mg/d Ketoconazole 400 mg/d Itraconazole 200 mg/d 100% (n = 16) 98% (n = 152) 100% (n = 17) 42% (n = 38) 83% (n = 94) 83% (n = 160) 94% (n = 136) 65% (n = 17) 75% (n = 16) 93% (n = 40) 60% (n = 52) 34% (n = 39) 71% 75% 65% 87% N/A 51% 68% 48% 20% 69% 73% 62% N/A 63% 60% at day 42 34% at day 42 46% at day 30 62% 37% at day 30 38% 40% at day 42 14% at day 42 11% at day 30 >80% at day 90 80% at day 60 22% 80% at a b c d e f b a c g h d h
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(n = 46) Itraconazole 200 mg/d Posaconazole 50 mg/d Posaconazole 100 mg/d Posaconazole 200 mg/d Posaconazole 400 mg/d Posaconazole 200 mg/d 93% (n = 46) 74% (n = 98) 80% (n = 102) 74% (n = 91) 83% (n = 100) 82% (n = 169) 72% 36% 37% 35% 40% 68% day 60 >80% at day 90 41% at day 30 38% at day 30 35% at day 30 36% at day 30 31% at day 30 g e e e e f
Esophageal Candidiasis
Fluconazole 100 mg/d Fluconazole 200 mg/d Itraconazole 200 mg/d Ketoconazole 200 mg/d Ketoconazole 200 mg/d Voriconazole 200 mg BID 85% (n = 72) 90% (n = 141) 100% (n = 12) 65% (n = 71) 91% (n = 19) 95% (n = 115) N/A N/A N/A N/A N/A N/A N/A N/A 58% at day 60 N/A 82% at day 60 N/A i j h i h j
BID = 2 times per day d = day N/A = not available
The cure rates for vulvovaginal candidiasis range from 72% to 98% in most trials of persons without HIV infection.(83-87) In the past, the standard treatment for vulvovaginal candidiasis typically consisted of topical clotrimazole or miconazole for 7 days. However, shorter courses have proved effective. Topical therapy for 3 days generally is equivalent to treatment with 7 days of topical medication. In a study comparing a 1-time dose of fluconazole (150 mg orally) with 7 days of topical clotrimazole therapy (100mg vaginal suppositories), the clinical cure rate (75%) in the 2 groups was equivalent by day 35.(87) Mycologic eradication rates at day 35 were 63% for the fluconazole group and 57% for the clotrimazole group. Either topical or systemic therapy generally is effective in women with HIV infection, but relapse rates may be quite high.(38) There are no prospective trials using real-time, in vitro susceptibility testing to guide the choice of antifungal therapy. A likely explanation is that most Candida infections respond to empiric therapy, and in vitro testing for antifungal resistance is not yet as reliable as antibiotic susceptibility testing of bacterial isolates. Some clinical fungal isolates found to be "resistant" by in vitro testing nevertheless respond to therapy. Less commonly, some
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Article 5: Mucocutaneus Candidiasis and HIV patients fail to respond to therapy despite having a relatively "sensitive" organism isolated. Thus, despite the determination of standard definitions for what constitutes in vitro resistance, more work must be done in this area before susceptibility testing can be used as a guide to antifungal therapy. There are a number of newer antifungals in varying phases of clinical development, including triazoles, echinocandins, sordarins, chitin synthase inhibitors, and topoisomerase inhibitors. Several new agents in the former 2 categories are now approved in the United States. In vitro activity of 3 new triazoles (posaconazole, ravuconazole, and voriconazole) appears to be quite good for Candida species, the latter agent having been licensed by the FDA in 2002.(88-94) A blinded, randomized study of voriconazole (200 mg twice daily) vs fluconazole (200 mg daily) for the treatment of esophageal candidiasis found no difference in the number of persons with endoscopically proven cure after 2-6 weeks of therapy: 94.8% of the voriconazole group (n = 115) vs 90.1% of the fluconazole group (n = 141).(73) Posaconazole (100 mg suspension/day) compared favorably to fluconazole (100 mg suspension/day) in the treatment of OPC in persons with HIV infection.(93) The clinical cure rate was 92% (n = 169) for posaconazole vs 93% (n = 160) for fluconazole. Similarly, posaconazole compared favorably to fluconazole in a dose-ranging study for the treatment of oral candidiasis in HIV infection.(94) Caspofungin, micafungin, and anidulafungin are members of the echinocandins, a novel class of antifungals. These agents also show promise in the treatment of Candida infections but are limited to parenteral administration at present.(95-97) In a study of 21 persons with esophageal or oral candidiasis, most of whom had HIV infection, who were treated with caspofungin, a favorable response was noted in 82% with esophageal disease and 100% with oral disease.(65) In a randomized trial comparing caspofungin with fluconazole for esophageal candidiasis, response rates and relapses at 4 weeks were similar. In the caspofungin group, 81% (n = 81) responded vs 85% (n = 94) in the fluconazole group.(98) Similarly, micafungin at a dose of 150 mg/day (n = 59) was similar in efficacy to fluconazole 200 mg/day (n = 60) for esophageal candidiasis (89.8% vs 86.7% response rate, respectively) in a randomized, double-blinded, multicenter study.(99) Refractory Candidiasis Reports of refractory OPC and esophageal disease began emerging in 1990.(16,58,59,100-114) Refractory vaginal candidiasis has remained relatively uncommon.(115) Refractory disease is defined as the failure to respond to antifungal treatment with appropriate doses for a standard duration of time (eg, 14 days).(16,115) Fluconazole-refractory disease has received particular attention because of significant morbidity, treatment often requiring the use of parenteral agents, and the frequency with which fluconazole has been prescribed. The annual incidence of fluconazolerefractory OPC was reported to be 4-5% in advanced HIV infection in developed countries prior to the introduction of combination ART.(16,37) Like most other opportunistic infections, fluconazole-refractory OPC is less common with the widespread use of effective ART. Candidiasis refractory to
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Article 5: Mucocutaneus Candidiasis and HIV amphotericin B is exceedingly uncommon.(116-120) Of note, clinical failures also may result from inadequate drug absorption or drug interactions that decrease the levels of some antifungal medications.(71,121,122) Refractory candidiasis tends to occur in persons with advanced HIV disease (CD4 lymphocyte counts <50 cells/L) who have been exposed to antifungal therapy on a continuous, chronic basis.(16) A longer median duration of exposure to antifungal therapy (419 vs 118 days, p < .001) and to systemic azole therapy (272 vs 14 days, p < .001) has been reported in comparing persons who had fluconazole-refractory OPC with matched controls.(104) In a randomized trial of episodic vs continuous use of fluconazole to determine which strategy for the prevention and treatment of mucocutaneous candidiasis would more likely lead to refractory candidiasis, no difference was observed in the rates of refractory disease (4.3% vs 4.1%, respectively).(123) Other factors that may predict the development of refractory candidiasis include use of prophylactic trimethoprimsulfamethoxazole and a history of prior opportunistic illnesses such as Mycobacterium aviumcomplex disease.(16) Similarly, chronic exposure to itraconazole results in higher rates of in vitro resistance, but these isolates typically remain susceptible to fluconazole.(124) Refractory candidiasis often is difficult to treat and may become increasingly unresponsive to therapy over time. The most important step is to determine what medications and dosages have been tried and whether adherence to therapy has been adequate. Removing any interacting medications or increasing the dose of the antifungal agent may be curative in some persons. In general, persons with OPC that is unresponsive to clotrimazole, nystatin, ketoconazole, or itraconazole tablets will respond to fluconazole. Persons with OPC unresponsive to fluconazole 200 mg daily given for 2 weeks are less likely to respond to higher doses but sometimes do respond. Additionally, flucytosine may be added for synergy. Options for managing fluconazole-refractory disease are listed in Table 5. There have been few controlled, comparative studies of these approaches. Parenteral amphotericin B (or liposomal preparations of amphotericin B) remains the drug of choice for persons with severe disease or esophageal involvement. For mild to moderate fluconazole-refractory OPC, amphotericin B oral suspension, itraconazole solution, or the addition of flucytosine are reasonable therapeutic strategies.(125-131) Overall, the response rate is 5060% for itraconazole solution and slightly lower for oral amphotericin B solution. Other options for treating fluconazole-resistant isolates include voriconazole, caspofungin, micafungin, and anidulafungin.(88,89) ART should be optimized in persons with refractory candidiasis. Treatment with protease inhibitors has been noted to result in clinical improvement in difficult-to-treat cases.(132) Protease inhibitors have been shown to inhibit Candida secretory aspartic proteases, demonstrating direct antifungal activity against Candida.(133-135) The duration of antifungal treatment for refractory disease is based upon the response, but typically a course of 14 days for OPC or vaginal disease, and 21-28 days for esophageal disease, is necessary. Relapse rates are high in persons with refractory disease, and maintenance suppressive therapy is universally required.(131) In challenging
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Article 5: Mucocutaneus Candidiasis and HIV cases, therapy 2-3 times weekly, or daily suppressive therapy on occasion, may be needed to avoid relapse.
Table 5. Therapeutic Options for Fluconazole-Refractory Mucosal Candidiasis Medication Dosage
Topical Therapy
Clotrimazole troches Gentian violet Amphotericin B oral solution* 100-500 mg 4-5 times per day Apply to oropharynx once (may repeat weekly as needed) 100 mg/mL, 5 mL PO QID
Systemic Therapy
Fluconazole tablets Flucytosine Itraconazole tablets Itraconazole solution* Amphotericin B deoxycholate Liposomal amphotericin B Caspofungin Micafungin Voriconazole 400-800 mg PO QD or BID 25 mg/kg PO QID (100 mg/kg/day) 200-400 mg PO QD or BID 40 mg/mL, 2.5-5 mL PO BID 0.5-1.0 mg/kg/day IV QD 3 mg/kg/day IV QD 50 mg IV QD 150 mg IV QD 100-200 mg PO QD or 4 mg/kg/day IV
Adjunctive Therapy
Combination antiretroviral therapy GM-CSF
#
RT inhibitors + protease inhibitors 300 mcg SC 3-5 times per week
* Controlled study supports use of this treatment for fluconazole-refractory candidiasis.(a,b) # Investigational BID = 2 times per day GM-CSF = granulocyte macrophage colony stimulating factor IV = intravenously PO = orally QD = once per day QID = 4 times per day RT = reverse transcriptase SC = subcutaneous
Invasive Candidiasis Despite the frequency of mucosal candidiasis, invasive disease is uncommon in persons with HIV infection. There are few studies describing the incidence and prevalence of nonesophageal invasive candidiasis in HIV-infected persons. Most studies are restricted to case series or anecdotal reports. A retrospective review found the incidence of candidemia to be 0.09 episodes per 100 person-years from 1992 to 1996 compared with 1.1 episodes per 100 person-years from 1997 to 2001, suggesting a decrease following the advent of effective ART.(136) Overall, the incidence of candidemia in AIDS is probably <1%.(137,138) Individuals who develop candidemia usually have risk factors known to be associated with invasive candidiasis (eg, indwelling intravenous catheter, neutropenia, chemotherapy, parenteral
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Article 5: Mucocutaneus Candidiasis and HIV alimentation).(136) The explanation for the lack of invasive disease in persons with HIV infection may be that the pathogenesis of invasive candidiasis usually involves disruption of a mucosal or skin surface barrier with subsequent hematogenous dissemination secondary to neutrophil and macrophage dysfunction--conditions that are not characteristic of HIV disease.(139,140) In a review of 14 cases of Candida meningitis in HIV-infected patients, a history of at least 1 predisposing risk factor was noted in 10 of the patients, 9 of whom were intravenous drug users.(140) Of interest, 4 of the patients had no risk factors identified. Candida meningitis remains a rare entity, even among other immunosuppressed patients, and optimal therapy is unknown. It seems prudent for HIV-infected patients with Candida meningitis to continue chronic suppressive therapy with fluconazole on a regimen similar to that used in the management of cryptococcal meningitis. Prevention The most important method of preventing mucocutaneous candidiasis is reversal of the immunodeficiency associated with HIV infection. Combination ART is the single best intervention to reduce the incidence of mucocutaneous candidiasis. Several studies demonstrate a decline in the rate of colonization and clinical disease with the use of potent ART.(42,43,47) This decline has been correlated with reduction in HIV-1 RNA levels in the plasma. Other possible interventions include smoking cessation, good oral hygiene, avoidance of unnecessary antibiotics and steroids, and specific antifungal medications. Although recurrent mucocutaneous candidiasis is frequent in persons with untreated advanced HIV infection, the indications for prophylactic antifungal therapy remain uncertain. A randomized study comparing clotrimazole and fluconazole demonstrated that fluconazole can prevent invasive fungal infections such as cryptococcosis and esophageal candidiasis.(141) However, that study found no survival advantage. Weekly fluconazole prophylaxis also has been studied for the prevention of OPC and vulvovaginal disease.(38,142,143) Another study reported decreases in the incidence of both OPC (relative risk [RR] = 0.50; 95% confidence interval [CI], 0.330.71) and vulvovaginal disease (RR = 0.56; 95% CI, 0.41-0.77) in a group of 323 women with moderately advanced HIV infection who took weekly doses of fluconazole 200 mg (median follow-up, 29 months).(38) Thus, although prophylaxis can reduce the risk of mucocutaneous candidiasis, there is no associated survival advantage. Furthermore, several studies have demonstrated that continuous, long-term exposure to antifungals such as fluconazole can lead to the emergence of resistance and refractory infections.(16) Consequently, most experts do not recommend universal primary antifungal prophylaxis. The use of secondary prophylaxis should be individualized. In a randomized study of continuous fluconazole prophylaxis vs episodic treatment with fluconazole in persons with prior mucosal candidiasis, continuous fluconazole resulted in fewer cases of OPC or esophageal disease (0.29 vs 1.08 per
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Article 5: Mucocutaneus Candidiasis and HIV patient-year; p < .001) and invasive fungal infections (15 vs 28 episodes; p = .04) though there was no difference in survival.(123) There was no increase detected in resistance among the continuous usage arm. The proportion of patients in whom the final candidal isolate was resistant to fluconazole was 50 of 110 (45%) in the continuous fluconazole arm and 79 of 218 (36%) in the episodic fluconazole arm (p = .11). Some experts recommend prophylaxis in persons with a prior episode of esophageal candidiasis.(144,145) In general, persons with occasional disease or infrequent recurrences of OPC (fewer than 3 episodes per year) can be treated for each episode. An alternative approach is to provide the patient with a supply of antifungal medications that can be initiated at the earliest sign of recurrence. This alternative may be useful for adherent, welleducated patients with frequent or disabling episodes, particularly at low CD4+ lymphocyte counts. Some experts recommend prophylaxis in persons with advanced HIV disease when prescribing antibiotics or corticosteroids, such as in a patient with Pneumocystis jiroveci pneumonia. If the decision is made to use prophylaxis, daily, thrice-weekly, or weekly fluconazole are the options most frequently cited in published studies. Ketoconazole and itraconazole probably are useful as well but have not been evaluated in controlled trials. Topical therapy may be useful in some patients. In summary, reserving continuous use of antifungal agents to those persons with frequent or severe recurrences of mucosal candidiasis is recommended in order to avoid the emergence of drug resistance, avoid drug interactions, simplify already complex drug regimens, avoid drug toxicity, and lower the cost of treatment.
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MOLECULAR AND CELLULAR MECHANISMS THAT LEAD TO CANDIDA BIOFILM FORMATION

SOURCE: http://jdr.sagepub.com/content/88/2/105/F5.expansion.html AUTHORS: J.M. ten Cate1,*, F.M. Klis2, T. Pereira-Cenci1,3, W. Crielaard1, P.W.J. de Groot21Department of Cariology Endodontology Pedodontology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Free University Amsterdam, Louwesweg 1, 1066 EA Amsterdam, the Netherlands; 2Swammerdam Institute for Life Sciences, University of Amsterdam, Amsterdam, the Netherlands; and 3Department of Prosthodontics and Periodontology, Faculty of Dentistry of Piracicaba, UNICAMP, Brazil DATE PUBLISHED: July 23, 2008
Abstract
Fungal infections in the oral cavity are mainly caused by C.albicans, but other Candida species are also frequently identified. They are increasing in prevalence, especially in denture-wearers and aging people, and may lead to invasive infections, which have a high mortality rate. Attachment to mucosal tissues and to abiotic surfaces and the formation of biofilms are crucial steps for Candida survival and proliferation in the oral cavity. Candida species possess a wide arsenal of glycoproteins located at the exterior side of the cell wall, many of which play a determining role in these steps. In addition, C.albicans secretes signaling molecules that inhibit the yeast-to-hypha transition and biofilm formation. In vivo, Candida species are members of mixed biofilms, and subject to various antagonistic and synergistic interactions, which are beginning to be explored. We believe that these new insights will allow for more efficacious treatments of fungal oral infections. For example, the use of signaling molecules that inhibit biofilm formation should be considered. In addition, cell-wall biosynthetic enzymes, wall cross-linking enzymes, and wall proteins, which include adhesins, proteins involved in biofilm formation, fungal-bacterial interactions, and competition for surface colonization sites, offer a wide range of potential targets for therapeutic intervention.
Introduction And Scope
Candida albicans and, to a lesser extent, other Candida spp. are
commonly found in the oral cavities not only of adults, but also of children, with a reported prevalence between 15 and 75%. They are recovered from the dentition, tongue, cheeks, and palatal mucosa and from restorative materials and prostheses. Candida spp. are also found associated with root caries (Zaremba et al., 2006) and observed in or next to infected gingival crevices (Shen et al., 2002). In healthy, dentulous persons, Candidapresence seldomly causes disease. The most prevalent pathology induced by Candida spp. is found in immunocompromised persons or in those with impaired salivary function. In denture-wearing individuals, Candida spp. often cause denture stomatitis, a mucosal infection in the tissue in contact with the prosthesis (Espinozaet al., 2003). Candida is found more often in
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Article 6: Molecular and Cellular Mechanisms That Lead to Candida Biofilm Formation
denture-wearing than non-denture-wearing edentulous persons (Daniluk et al., 2006). Current research now encompasses a dozen Candida species. Although Candida spp. were already identified in 1936 as a cause for denture-related infections (Cahn, 1936), considerable progress in understanding the etiology and pathogenesis of this disease has only recently been made. Undoubtedly, this is the result of the various molecular biological methodologies that have been developed and the availability of genomic data. Also, it is now acknowledged that Candida spp.colonize surfaces in a biofilm. In the mouth, Candida will typically reside in mixed biofilms, with bacterial-fungal interactions dictating overall properties and survival of the respective species (for review, see Mukherjee et al., 2005). In contrast to most other Candida spp., C.albicans is able to switch between the yeast and the hyphal mode of growth, thus combining the better dispersal properties of the yeast form with the invasive properties of the hyphal form. This additional virulence factor contributes to the prevalence of C.albicans in fungal infections compared with other Candida spp. To complicate this picture further, it has been observed that the substratum to which fungi adhere may trigger a genetic response leading to this morphological shift. A genetically dictated cascade of events (hyphae formation, quorum sensing) is decisive for biofilm formation and/or penetration into underlying tissue (Nobile and Mitchell, 2006). Biofilm formation is a survival mechanism to ensure residence in the mouth. In biofilms, the bacteria and fungi are typically encapsulated into a matrix of glycoproteins and polysaccharides produced by the microbial components, and they often reside in a (seemingly dormant) state of reduced metabolic activity. Biofilm inhabitants, fungi and bacteria, are less sensitive or insensitive to antifungal treatments. Candida spp. adhere not only to denture surfaces, but also to other medical devices, such as voice prostheses (Holmes et al., 2006), blood and urinary catheters (Jain et al., 2007), and heart valves (Salamon et al., 2007). Therefore, the study of Candida adherence to surfaces has a much broader scope and relevance than for oral-dental issues. Candida present in the oral cavity serves as a reservoir for inoculation and infections elsewhere in the body. The fact that Candida spp. are present all through the body is reflected in prevalence data in feces (734%) (Jobst and Kraft, 2006). When Candida penetrates the epithelium and invades the host tissues, this may lead to bloodstream infections and systemic infections. These are difficult to treat with antifungals and therefore have a high reported mortality (40%) (LaFleur et al., 2006; Pfaller and Diekema, 2007). In total, this explains and justifies the increased attention
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to Candida spp. in oral ecology. In this review, we focus on surface reactions relevant to biofilm formation, in particular, on the cell-wall proteins of Candida species and on the interactions of bacteria and fungi in mixed biofilms. Morphology And Evolutionary Relationships Of Candida Species
Figure 1. Neighbor-joining phylogenetic tree indicating the evolutionary relationships between sequenced Candida species and S. cerevisiae based on 18S rDNA sequences. 18S rDNA of the species was found with BLAST against databases containing the genomic DNA assemblies, with the S. cerevisiae RDN18-1 gene as the query. S. pombe was used as the outgroup. C. glabrata CBS138 and S. pombe (strain 971) 18S rDNA was retrieved from GenBank. The tree was calculated with ClustalX, with correction for multiple substitutions using the 18S rDNA alignment produced with MUSCLE (Edgar, 2004), and plotted with NJplot (Perrire and Gouy, 1996) with bootstrap values added (1000 bootstraps performed).
Although C.albicans is still the main cause of candidiasis, other speciessuch as C.glabrata, C.dubliniensis, C.parapsilosis, C.krusei, and C.tropicalisare becoming increasingly prevalent. This may be related to the (prophylactic) use of antimycotics such as azoles. In many epidemiological surveillance studies, C.glabrata is ranked as the second most prevalent species after C.albicans. Remarkably, C.glabrata is phylogenetically closer to common bakers yeast (Saccharomyces cerevisiae) than to other Candida spp. (Dujon et al., 2004) (Fig. 1). C.glabratas yet-unexplained resistance to azole medication makes infections caused by C. glabrata difficult to
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treat. C. dubliniensis is particularly associated with oral candidiasis in HIV-infected individuals, presumably because C.dubliniensis tends to build up resistance against azoles much faster than does C.albicans, resulting in the replacement of C.albicans with C.dubliniensis (Martinez et al., 2002; L Li et al., 2007).
C.albicans is the species most frequently encountered in infected
tissues, including oral mucosal layers. It is also the predominant species found during vaginal and invasive bloodstream infections. In contrast to most other Candida spp., C.albicans is a pleomorphic fungus exhibiting different modes of growth (Figs. 2, 3, 5) (Table 1). It can not only proliferate a unicellular budding yeast, but also, when triggered by specific environmental conditionssuch as a growth temperature of 37C, neutral or alkaline pHs, increased CO2 concentrations, or the presence of serumit may undergo morphological switching, leading to elongated growth forms, termed pseudohyphae and hyphae. Collectively, these are named filamentous forms (Sudbery et al., 2004). Hyphae are characterized as unconstricted filaments with parallel-sided walls. In contrast, pseudohyphae seem to represent a growth form between those of yeast and hyphae, in which the cells remain attached to each other, but can vary in shape, from elongated ellipsoidal cells to forms that superficially closely resemble hyphae. The various growth forms are important for the establishment of Candida infections, with specific roles proposed in adhesion, biofilm formation, tissue penetration, and organ colonization (Fig. 2) (Kumamoto and Vinces, 2005). An overview of some important properties of the various Candida spp. is presented in Table 1.
Table 1. Comparison of Properties of Different Pathogenic Candida Species and S. cerevisiae
Properties
C.albicans
C. C. C. dubliniensis parapsilosis tropicalis
C. krusei
C. S. glabrata cerevisiae
Genome sequenced Ploidy CTG clade Pseudohyphae Hyphal formation

Chlamydospores
Yes 2N Yes Yes Yes Yes Yes
Yes 2N Yes Yes Yes Yes

Presumably
Yes 2N Yes Yes No No No
Yes 2N Yes Yes No No No
No 2N Yes Yes No No
Unknown
Yes 1N No Yes No No No
Yes 1N/2N No Yes No No No
Hwp1 as transglutaminase substrate
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Figure 2. Schematic model indicating multi-species biofilm formation and development of Candida infections.
Figure 3. The cell wall of Candida albicans. (A) Cryo-scanning electron microscopy of C.albicans yeast and hyphal cells (Tokunaga et al., 1986). Note the fibrillar nature of the outer protein layer. (B) Schematic representation of the cell wall of C.albicans, which consists of an inner skeletal layer composed of the stress-bearing polysaccharides -1,3-glucan and chitin (black lines), which run parallel to the cell surface. The inner layer is kept together by extensive hydrogen bonding between individual -1,3-glucan chains and by the -1,3-glucan cross-linking protein Pir1 (X). This three-dimensional skeletal network acts as a scaffold for a dense outer layer of glycoproteins (grey lines) extending into the environment and linked through their C-terminus to a flexible -1,6glucan moiety (grey ovals), which in turn is linked to -1,3-glucan. The outer layer covers the inner layer and helps the cell to avoid recognition of the -1,3glucan chains by the dectin-1 receptor of the innate immune system. The cell wall is flexible and highly extended under normal osmotic conditions. Consequently, fixed cells are smaller than live cells.
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The Molecular Architecture Of The Cell Wall Of Candida Albicans Adherence and aggregation of Candida with abiotic surfaces, bacteria, or other fungi depend on surface reactions. Therefore, it is important to study the cell-wall properties of Candida spp. The cell wall of C.albicans consists of 4 major components: (i) mannoproteins, which account for about 40% of the cell-wall biomass; (ii) -1,3 glucan, the major stress-bearing polysaccharide of the wall; (iii) -1,6glucan, a water-soluble component without a regular structure that interconnects mannoproteins to -1,3-glucan and chitin chains; and (iv) a small amount of chitin (a linear stress-bearing polysaccharide consisting of -1,4-linked N-acetylglucosamine residues). -1,3-glucan forms a three-dimensional, hydrogen- bond-stabilized, network of fibrils that run parallel to the cell surface. Chitin bound to -1,3-glucan further strengthens this network. The molecular architectures of the yeast and hyphal wall of C.albicans are similar. However, the composition of its cell wall, particularly its protein composition, is variable and strongly depends on environmental conditions (Nett et al., 2007;Sosinska et al., 2008; Walker et al., 2008; Yin et al., 2008). The cell wall of C.albicans is essentially bi-layered, with an internal skeletal layer that is surrounded by a coat of fibrillar proteins that emanate outward (Tokunaga et al., 1986; Kapteyn et al., 2000) (Fig. 3). Most of the cell-wall proteins (CWPs) are GPI-proteins (GPI, glycosylphosphatidylinositol). They generally consist of a cell-surfaceexposed amino-terminal effector domain that is supported by a spacer domain; in addition, they have carboxy-terminal features, including a remnant of a GPI-anchor that causes covalent attachment to the cellwall -1,3-glucan network (Kapteyn et al., 2000; Klis et al., 2006). The synthesis of -1,3-glucan is blocked by the new echinocandin class of drugs (anidulafungin, caspofungin, and micafungin). They are fungicidal and active against a wide spectrum of fungi (Cappelletty and Eiselstein-McKitrick, 2007). Whereas GPI-CWPs are predominantly found at the outside of the cell wall, immunogold labeling has shown that the cell-wall protein CaPir1 (Protein with Internal Repeats) is uniformly distributed throughout the inner skeletal layer (Kapteyn et al., 2000). Pir1 possesses multiple tandem repeats through which it probably cross-links -1,3-glucan chains, thus being vital for the mechanical strength of the skeletal wall layer (Martnez et al., 2004; Ecker et al., 2006). Because the crosslinking process between -1,3-glucan chains takes place outside the plasma membrane, this particular reaction provides a rational and promising target for compounds designed to inhibit fungal growth and biofilm formation in the oral cavity. While the original work was done on C.albicans, all available evidence now indicates that the molecular architecture of the walls of Candida spp. is highly similar (Frieman and Cormack, 2003; Weig et al., 2004; De Groot et al., 2005). This would
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imply that any agent interfering with the cell-wall structure of C.albicans is likely to affect all Candida spp.and probably many other ascomycetous fungi as well. A Wide Arsenal Of Cell-Wall Proteins (CWP) Dictates Candida Albicans External Reactions Mass spectrometric analysis of the cell-wall proteome in combination with immunological analysis has shown that, at any time, there are about 20 or more different covalently linked CWPs in the cell wall of C.albicans, most of them GPI-CWPs. However, the protein composition of the wall can differ considerably, both quantitatively and qualitatively (De Groot et al., 2004; Sosinska et al., 2008). CWPs determine cell-surface properties such as hydrophobicity, immunogenicity, negative charge, and permeability toward large macromolecules (Yin et al., 2008). They also promote endocytosis by endothelial cells, iron acquisition, and coping with oxidative stress (Holmes et al., 2006; Phan et al., 2007; Hoyer et al., 2008; Yin et al., 2008). Other CWPs are involved in binding of saliva proteins, adhesion to epithelial cells and to teeth and dental prostheses, and in biofilm formation. They are also known to interact with bacterial surface proteins, resulting in co-aggregation and the formation of mixed biofilms (Klotz et al., 2007) (Table 2). Conceivably, some CWPs are involved in the production of the extracellular matrix that encases biofilm cells. The presence of such a wide arsenal of glycoproteins in the external wall layer offers various opportunities for the development of new drugs counteracting biofilm formation and infection in the oral cavity (see Perspectives, below). Adhesins represent a special class of GPI-CWPs that have important functions in fungal colonization of the oral cavity. Two prominent classes of adhesins can be distinguished: first, the immunoglobulin (Ig)-like adhesins such as the Als (Agglutinin-like sequence) family, found in all Candida spp. except C. glabrata (Hoyer et al., 2001); and second, the Epa (Epithelial adhesion) family of lectin-like adhesins, found only in C. glabrata (Kaur et al., 2005). Some other adhesins, such as CaHwp1 and CaEap1, also play an important role in fungal colonization.
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Table 2. Role of Candida Cell-surface Glycoproteins in Adhesion and Biofilm Formation, and in Cell-wall Cross-linking Steps 1 Protein Properties Function References
1
Gene products in the different species are referred to by their genus and species initials, followed by the locus name.
Adhesion and biofilm formation

CaAls family Immunoglobulin-like N-terminal domain; tandem repeats in central region; serine- and threonine-rich C-terminal region N-terminal lectin-like domain followed by a S/T-rich domain containing tandem repeats Adhesin-like modular structure with unique N-terminal domain Transglutaminase-substrate domain in N-terminal region Adhesion to epithelial cells and intra- and interspecies cell-cell interactions Adhesion to epithelial cells; biofilm formation Adhesion to epithelial cells; biofilm formation Covalent bonding of C.albicans to host epithelia Klotz et al., 2004, 2007; Dranginis et al., 2007; Hoyer et al., 2008 Iraqui et al., 2005; Kaur et al., 2005; Zupancic et al., 2008 Li and Palecek, 2003; F Li et al., 2007 Staab et al., 2004
CgEpa family
CaEap1
CaHwp1
CaSun41
Non-GPI-CWP with a conserved Biofilm formation C-terminal domain Glutamine-rich internal repeats Cross-linking of function as attachment sites for different -1,3-1,3-glucan glucan chains GPI-CWPs with 1 Pir-repeat sequence Transglycosidases Cross-linking of 1,6-glucan and 1,3-glucan
Hiller et al., 2007
Cross-linking
CaPir1 Martnez et al., 2004 De Groot et al., unpublished observations
CgCwp1.1 and 1.2 CaCrh1 and Utr2
Involved in crossPardini et al., 2006 linking -1,3-glucan and chitin Cleavage of GPI Spreghini et al., anchors and 2003 possible coupling to -1,6-glucan
CaDfg5 and Dcw1 PM localized GPI-proteins with homology to bacterial endomannosidases Gas family PM localized GPI-proteins with a transglucosidase function
The Als and Epa Families of Adhesins All Als adhesins in C.albicans have a similar modular structure with an amino-terminal, Ig-like domain, a Thr-rich middle part composed of tandem repeats, and a heavily glycosylated serine (Ser)- and threonine (Thr)-rich spacer domain (Dranginis et al., 2007; Hoyer et al., 2008). The lectin-like Epa proteins in C. glabrata, which are involved in adhesion to host cells, have a comparable modular structure. They also have an amino- terminal effector region, including the recently discovered PA14 domain that is responsible for sugar specificity (Zupancic et al., 2008), followed by a Ser- and Thr-rich
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middle part consisting of a variable number of tandem repeats, and a Ser- and Thr-rich tail without a periodic structure. The number of tandem repeats in adhesion proteins tends to vary considerably among different strains, resulting in allelic variability. Two Unique C.albicans Adhesins Another important adhesin is CaEap1, which mediates adhesion to hydrophobic surfaces, such as polystyrene, and, most likely, to polymer materials used in medical devices (Radford et al., 1999; Li and Palecek, 2003). Eap1 is a typical GPI-protein with a modular structure comparable with that of the Als and Epa proteins; however, it seems unique to C.albicans, since no obvious ortholog can be found in other Candidaspecies (Li and Palecek, 2008). Eap1 has also been shown to mediate attachment to kidney epithelial cells and is required for C.albicans biofilm formation (F Li et al., 2007). The GPI-modified CWP Hwp1 (Hyphal wall protein 1) is strongly, but not exclusively, expressed in hyphal walls of C.albicans and has been found to be required for normalC.albicans biofilm formation (Nobile et al., 2006). Hwp1 offers a unique insight into how C.albicans can survive in the oral cavity and elsewhere in the human body, notwithstanding the fact that it is subject to considerable shearing forces and to continuous flushing of the oral cavity by saliva. The effector domain of Hwp1 is enriched in glutamine residues, but very poor in serine and threonine residues, whereas the reverse holds for the subsequent domain (Fig. 4). It has been shown that the aminoterminal effector region, which extends into the environment, is recognized as a suitable substrate for transglutaminase activity associated with the cell surface of oral epithelial cells (Staab et al., 2004). As a result, isopeptide cross-linkages are formed between Hwp1 and extracellular matrix proteins of epithelial cells. This example of molecular mimicry is thus responsible for irreversible binding ofCandida cells to the epithelial layer. Hwp1 is found in C.albicans, and a similar (orthologous) protein has been identified in C. dubliniensis, but it seems to be absent from other Candida species. It seems likely that more adhesins will be discovered in the future. The occurrence of so many and such diverse wall-bound adhesins clearly illustrates how well Candida is adapted to living in warm-blooded animals.
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Figure 4. The cell-wall protein Hwp1 of Candida albicans: a case of clever molecular mimicry. (A) Schematic representation of CaHwp1 shows that the predicted polypeptide chain consists of an N-terminal signal peptide, which is required for entry into the endoplasmic reticulum. (B) The signal peptide is directly followed by a glutamine (Q)-rich domain. This domain is recognized as a valid substrate by an epithelial cell-associated transglutaminase, which then covalently links C.albicans cells to oral epithelial cells (Staab et al., 2004). (C)The N-terminal effector domain is followed by a region that is rich in the hydroxyamino acids serine (S) and threonine (T) and therefore potentially highly glycosylated with short O-linked side-chains. This region acts as a spacer domain. The polypeptide chain terminates in a GPI anchor addition signal peptide, which, in the endoplasmic region, is replaced by a GPI anchor. The mature protein is linked through a truncated form of its GPI anchor to the skeletal framework (Kapteyn et al., 2000).
Substratum Properties The oral cavity consists of a multitude of substrata to which microorganisms and fungi may adhere. Early in life, there is just the mucosal tissue, and then the dentition emerges. With increasing age, new substrata are placed in the mouthvarious restorative materials, gold, porcelain crowns, acrylic dentures, silicon denture liners, and titanium implantswhile the mucosal layers undergo an aging process. Most of the early work on bacterial and fungal adherence was done by characterizing the substratum by its surface free energy, hydrophobicity, and surface roughness. All these parameters are predictive for Candida adherence. Materials with the roughest surface
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usually exhibit higher adherence (Nevzatolu et al., 2007), because such surfaces provide an increased chance of microbial retention and protection from shear forces. C.albicans nested in rougher surfaces was also found to be less sensitive to antifungal treatments (Tsang et al., 2007). Since bacteria and fungi have different dimensions, a given roughness may specifically accommodate micro-organisms that fit the provided irregularities (Whitehead et al., 2005). While being necessary to disclose adherence mechanisms, a general shortcoming of experimental studies on well-characterized substrata is that there are often hidden confounding factorssuch as, materials being found to release compounds that have antimicrobial properties, as for monomers in acrylic resins, or acquiring scratches during wear that prove to be favorable nesting sites. Denture liners are of particular relevance for Candida-related stomatitis. Liners are used to overcome sharp ridges of dentures and are often made of silicon material. They typically have a higher roughness than the acrylic denture and show porosities when inspected under the scanning electron microscope (Nevzatolu et al., 2007;Pereira-Cenci et al., 2008). Aging of acrylic and liner surfaces results in increased roughness, and therefore increased attachment (Nikawa et al., 2001). Liners are sometimes provided with antifungal agents, which leach out. Various observations have indicated that this may add to the aging process. Porous liners also take up endotoxins produced by the denture plaque, providing a slow release base for infection-inducing molecules. A study of biofilm formation on lining materials showed that inhibition of Candida growth, due to the released antifungal, was limited to a thin layer close to the surface (Fig. 5) (Pereira-Cenci et al., 2008). With our current knowledge on mixed bacterial fungal biofilms, new research initiatives to develop antifungal liners should lead to better materials.
Candida spp. are isolated from various sites in the mouth, including
the oral soft tissues. In an unhygienic oral environment, biomaterials may act as a reservoir of infection for respiratory and systemic opportunistic pathogens (Sumi et al., 2002,2003; Nikawa et al., 2006), presenting a niche for the development of biofilms containing antibiotic-resistant micro-organisms (Smith et al., 2003), and ultimately resulting in plaque-associated oral diseases. Exogenous acquisition of C.albicans via contaminated biomaterials may also lead to systemic infections.
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Figure 5. Confocal laser scanning micrographs of mixed Candida-bacterial biofilms. The pictures show the yeast and hyphal morphological forms of Candida albicans,whose transition is influenced by various factors such as the type of carbon source (sugar), and the presence of saliva and/or other fungi or bacteria. Panels A and B were taken from mixed C.albicans- S. mutans biofilms, either(A) close to the biofilm outer surface, showing merely C.albicans, or (B) in the biofilm close to the lining material, showing mainly S. mutans. Panels C and D are also examples of mixed biofilms of C.albicans-S. mutans, grown on hydroxyapatite, in the presence of (C) sucrose and (D) glucose, respectively, which illustrates differences in morphological forms depending on carbon nutrient source. Square dotted arrows show C.albicans in the yeast form; dashed arrows show C.albicans in the hyphal morphology; dashed and dotted arrows show S. mutans.
Candida hyphae are usually found in the keratinized layer and rarely
penetrate epithelial cells. However, this may happen in extremely immune-compromised individuals (Neville et al., 2002). C.albicans may also invade the oral mucosa and persist within the epithelium, causing superficial lesions (Fidel, 2006). Additionally, type IV collagen binds to C.albicans and is a candidate for mediating the adherence of this species to the extracellular matrix and basement membranes of endothelial and epithelial cells of the host (Klotz, 1990). This is considered a crucial step in the development of candidiasis (Alonso et al., 2001). Whereas the high turnover rate of the epithelial tissue and the innate defense mechanisms may hinder deep penetration, C.albicans possesses offensive strategies, in particular morphological
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switching, which may result in oropharyngeal and systemic infections. Currently, attempts are under way to identify genes involved in fungal infections in oral epithelial tissues (Zakikhanyet al., 2007; Jayatilake et al., 2008). Studies dealing with bacterial and fungal initial adherence have traditionally worked with clean systems, involving merely microorganisms and substrata. Obviously, the oral cavity is considerably more complex, with saliva present as fluid and deposited as pellicle. The substratum dictates the composition of the pellicle, and, more importantly, the pellicle masks many of the properties of the underlying substratum (Gocke et al., 2002). Saliva immersion decreases the surface roughness and surface free energy of acrylic resins, and this might explain the general decrease of Candidaspecies in those in vitro studies where specimens were coated with saliva (Sipahi et al., 2001). However, it has also been reported that denture pellicle lacks salivary statherins and histatin, important salivary defense molecules (Edgerton and Levine, 1992). While C.albicans was for a long time the only fungus studied in adherence studies, recently other Candida spp. have been included. These findings have added considerably to the complexity of the adherence model, because salivary effects also differed among species (Moura et al., 2006; Pereira-Cenci et al., 2007). Examples of the current controversy are multiple: C. dubliniensis adherence has been shown to decrease (Elguezabal et al., 2004), to increase (Ramage et al., 2001), or to be unaffected (Moura et al., 2006) in the presence of saliva, while C. glabrata counts were not influenced by saliva in one study (Moura et al., 2006), but decreased in another report (PereiraCenci et al., 2007). This also highlights the importance of studying various Candida spp. in their adherence properties and the risk of extrapolating findings obtained with a particular species to other Candida spp.
Candida Biofilms And Candida-Bacterial Interactions Candida biofilm cells are generally much more resistant to anti-fungal
agents than are their planktonic counterparts. Despite its obvious clinical relevance, the molecular mechanisms underlying this phenomenon are not fully understood (Mukherjee et al., 2005; Ramage et al. 2005; dEnfert, 2006). Apparently, biofilm resistance is a complex multifactorial phenomenon. Multidrug efflux pumps (ABC transporters) have been suggested to contribute to the increased resistance of cells in the early stages of biofilm formation (Ramage et al.,2002a; Mukherjee et al.,2003). Inhibition of diffusion of antifungals by the extracellular biofilm matrix and the presence of antifungal
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persister cells may also be relevant (Al-Fattani and Douglas 2006; LaFleur et al., 2006; Al-Dhaheri and Douglas, 2008). Recently, a possible role for -1,3-glucan in antifungal resistance was postulated after it was shown that cell walls from biofilm cells could bind (and hence neutralize) antifungals better than planktonic variants, and that exogenous -1,3-glucan reduced the activity of fluconazole against planktonic C.albicans cells (Nett et al., 2007). Another contributing factor might be the role of cross-resistance. It has been frequently observed that mild forms of stress may prepare cells for subsequent (increased) stress conditions of a different nature (Arguelles, 1997; Kara et al., 2006). Biofilm cells live in a nutrient-poor, hypoxic environment, and it is conceivable that the suboptimal growth conditions in bio-films may result in increased tolerance to various forms of stress, including antimycotics-related cellular stress. Since C.albicans and other Candida spp. share their (oral) environment with many bacterial species, the question arises whether bacterialfungal interactions can affect biofilm formation, morphology, and virulence of Candida. This is indeed the case. C.albicans can bind to the oral microbes Streptococcus gordonii, Streptococcus oralis, and Streptococcus sanguinis, resulting in co-aggregation. This interaction is mediated by streptococcal cell-wall polysaccharides and cell-surface proteins and by as-yet-unknown Candida adhesins and is promoted by specific salivary proteins (Holmes et al., 1995, 1996; OSullivan et al., 2000). Not only direct physical cell-cell interactions can affect biofilm formation and virulence, but also indirect interactions mediated by secreted metabolic byproducts and by extracellular signaling molecules, such as quorum sensing molecules (Wargo and Hogan, 2006). Interactions between and among different host microbes in the oral cavity may have inhibitory effects on surface colonization and biofilm formation. For example, competition between different Candida species (C.albicans and Candida krusei) and between Candida and bacteria has been reported, with an additional modulating effect by saliva (Thein et al., 2007). A negative correlation between Porphyromonas gingivalis and C.albicans biomass in a biofilm gave rise to speculation on a possible inhibition of Candida colonization exerted by this periodontal pathogen in the gingival crevicular area (Thein et al., 2006). It was further shown that morphological transitions, and thereby virulence, can be influenced by the presence of oral bacteria in a Candida biofilm (Fig. 5) (Thein et al., 2006; Pereira-Cenci et al., 2008). The role of the quorum-sensing molecules secreted by C.albicans has been studied in considerable detail. C.albicans uses at least two quorum-sensing molecules, tyrosol and farnesol. Under conditions permissive for germ-tube formation, tyrosol stimulates hyphal
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formation in C.albicans, whereas farnesol inhibits the transition from yeast to hyphal growth (Hornby et al., 2001; Chen et al., 2004). Recently, it was found that C.albicans also secretes dodecanol, which also inhibits the yeast-to-hypha transition (Martins et al., 2007). Importantly, culture supernatants from mature C.albicans biofilms inhibit filamentous growth by planktonic C.albicans cells, which may indicate that farnesol and/or dodecanol is produced in situ in biofilms (Ramage et al., 2002b). Further, farnesol has been shown to interact with the cell membranes of several bacterial species, including those that are present in multispecies oral biofilms. As a result, bacterial growth, metabolism, and polysaccharide formation are affected (Kooet al., 2003). Studies on the effects of farnesol on Staphylococcus aureus (biofilms) substantiated the effect on bacterial cell membranes, but, more importantly, showed sensitization of S. aureus (and Escherichia coli) to various antimicrobials upon pre-exposure to farnesol (Brehm-Stecher and Johnson, 2003; Inoue et al., 2004). The fact that farnesol inhibits biofilm formation by staphylococci (Jabra-Rizk et al., 2006) indicates that it has great potential in the control of mixed Candida-bacteria biofilms.
Candida signals affect bacteria, but likewise bacterial quorum-sensing molecules can have an effect on C.albicans. The bacterial quorum-
sensing signals 3-oxo-C12 homoserine lactone and cis-11-methyl-2dodecanoic acid both modulate filamentation, and thereby virulence, in C.albicans (Hogan et al., 2004; Wang et al., 2004). For example, the signaling molecule homoserine lactone plays a role in the medically important interactions between C.albicans and Pseudomonas aeruginosa, which separately or together form biofilms on medical devices, and increase each others resistance toward antimicrobials (see Hogan and Kolter, 2002; Pierce, 2005; Wargo and Hogan, 2006). An example of an even more complex cross-signaling that may occur in a mixed biofilm is the observation that farnesol reduces the production of the (Pseudomonas) signaling molecule quinolone in cultures of P. aeruginosa (Cugini et al., 2007). The quinolone signal in P. aeruginosa regulates virulence factors such as the synthesis of pyocyanin, a redox-active phenazine compound that inhibits growth ofC.albicans (Kerr et al., 1999). This complex chemical interaction may promote C.albicans survival. Perspectives, Research Opportunities / Needs, Concluding Remarks In attempts to design an experimental model to mimic the oral conditions, it becomes evident how complex such a system should be to account for all the parameters involved. Moreover, many of these
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parameters have hardly been studied in their effects on fungal growth in an oral biofilm: flow dynamics, (an) aerobicity, and nutrient availability influence on the matrix density and thickness of biofilms (Al-Fattani and Douglas, 2006; Thein et al., 2007), which in turn determines its erosion and hence dissemination of fungi to other sites in the body. Most studies on fungal adherence have been carried out in simple, clean, presumed one-parameter experiments with single type strains. It would seem logical to include at least saliva in such studies, as is now often done. However, saliva in itself is a source of variation, since its composition depends on the salivary gland, time of the day, and general health of the donor. In older persons, the use of multiple medications typically affects saliva production, both directly and by affecting the persons immune system. Therefore, it is important to include well-characterized saliva in model studies, since the mentioned parameters are established risk factors for Candidainduced pathology. The available literature (in particular the many controversial findings) convincingly shows that adherence of Candida spp. to denture materials should be studied in more complex or multiple models, with findings being confirmed in vivo, for meaningful and relevant conclusions to be reached. To this end, a model was developed where replaceable acrylic disks were placed in cavities in dentures and recovered after various time periods. Duration, acrylic type, and patient variables could then be controlled (Avon et al., 2007). Given the above description of fungal life and survival in biofilms, the question may be raised, how can (fungal) biofilm formation be prevented? One approach is the use of signaling molecules secreted by C.albicans, such as farnesol and dodecanol, which inhibit the switch from yeast to hyphal cells and biofilm formation (Martins et al., 2007). In addition, several bacterial species living in mixed biofilms are known to inhibit the growth of Candida spp., or to inhibit the switch from yeast to hyphal growth, thus impeding biofilm formation. Identification of the responsible compounds could provide clues for more effective antifungal treatments. Alternatively, the extracellular cross-linking of -glucans by Pir1 and other cell-wall cross-linking steps represent attractive targets to prevent biofilm formation and infection in the oral cavity. Extracellular cell-wall construction steps have the advantage (as targets for treatment) that potential inhibitory compounds do not have to pass the plasma membrane, and thus do not have to be hydrophobic. Combination strategies are also worth considering. For example, a 1,6-glucan oligosaccharide in combination with a membrane-active peptide synergistically inhibits the growth of yeasts (Bom et al., 2001). Conceivably, a derivative of histatin 5 (a histidine-rich, salivary
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antimicrobial peptide) could be used together with cell-wall inhibitors (Zhu et al., 2006). Other successful combinatorial approaches are based on the use of calcineurin inhibitors, such as the immunosuppressive drugs FK506 and cyclosporine, in combination with fluconazole, resulting in strong inhibition of Candida albicans biofilm formation and even the killing of C.albicans (Uppuluri et al., 2008). Importantly, genomic libraries of tagged deletion strains allow for the systematic identification of successful drug combinations (Zakrzewska et al., 2007). Another promising development is the design of short antifungal -peptides. These are composed of synthetic, -substituted amino acids, which are resistant to proteolytic degradation. In addition, they kill C.albicans cells at concentrations that do not cause lysis of red blood cells and are active under physiological ionic conditions which tend to abrogate the activity of histatins (Karlsson et al., 2006). Raising antibodies directed against the effector domains of specific CWPs such as CaAls1 and CaAls3, functionally the two most important members of the Als family inC.albicans, or against CaHwp1, or CaEap1, may also be considered. Vaccination with the recombinant effector domains of CaAls1 and CaAls3 has already been shown to protect mice against disseminated and mucosal candidiasis (Spellberg et al., 2006). Furthermore, the CWPs known to be required for biofilm formation can be targeted in this way. Ideally, a multivalent vaccine should be developed that inactivates the most important CWPs involved in biofilm formation (Yin et al., 2008). In summary, research in recent years has resulted in significant advances in our knowledge of the surface properties of Candida spp. and of (mixed) biofilm formation which, when considered collectively, should lead to progress in the prevention and treatment of Candida-associated oral diseases.
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SUCCESSFUL TREATMENT OF CHRONIC MUCOCUTANEOUS CANDIDIASIS CAUSED BY AZOLE-RESISTANT CANDIDA ALBICANS WITH POSACONAZOLE 83

SOURCE: http://www.hindawi.com/journals/cdi/2011/283239/ AUTHORS: David Firinu,1 Orietta Massidda,2 Maria Maddalena Lorrai,1 Loredana Serusi,1 Monica Peralta,1 Maria Pina Barca,1 Paolo Serra,1 and Paolo Emilio Manconi1 1Department of Internal Medicine, Allergy and Clinical Immunology, Azienda Ospedaliero Universitaria, University of Cagliari, Italy 2Department of Biomedical Sciences and Technologies, Medical Microbiology, University of Cagliari, Italy DATE PUBLISHED: November 3, 2010 Abstract Refractory or recurrent infections of skin, nails, and the mucous membranes are clinical signs of chronic mucocutaneous candidiasis, frequently associated with immunological defects. Here we describe a 39-years-old female patient, with familial CMC, that presented with an extensive infection caused by an azole-resistant Candida albicans isolate, successfully treated with posaconazole.
Introduction Chronic mucocutaneous candidiasis (CMC) is a persistent or refractory/ recurrent infection of the skin, nails, and mucous membranes, most commonly caused by Candida albicans, that can be related to a variety of disparate clinical conditions, yet to be fully identified[1]. Although different underlying diseases predispose to CMC, they are frequently associated with primary or secondary immunodeficiencies. Regarding secondary causes, HIV infection is common, although other etiologies are known[1]. Among inherited causes, sporadic, autosomal dominant (MIM 114580), and autosomal recessive (MIM 212050) forms of CMC have been described. Moreover, similar clinical patterns of candidiasis are shared by other primary immunodeficiencies, mainly APECED (MIM 240300)[2] and autosomal-dominant hyper-IgE syndrome (MIM 147060)[3]. The availability of azoles (e.g., clotrimazole, ketoconazole, itraconazole, and fluconazole) represented a dramatic improvement in the treatment of all forms of CMCs. However, following the use of these drugs, C.albicans strains resistant to azole antifungals have been subsequently isolated [4], requiring novel therapeutic options. These include flucytosine, amphotericin B, the newest azoles and, more recently, echinocandins. Here we describe a case of a familial CMC, characterized by a refractory infection caused by C.albicans resistant to azoles, including voriconazole, successfully treated with posaconazole that to our knowledge has not yet been reported to treat these forms of candidiasis. Case Presentation
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Article 7: Successful Treatment of Chronic Mucocutaneus Candidiasis Caused by AzoleResistant Candida Albicans With Posaconazole
A 39-year-old female patient was referred to our Center in 2009, presenting a history of recurrent infections with involvement of mucosa, nails, and skin caused by C.albicans. At the onset, when the patient was 2years old, the fungal infection started on the face and nails and progressively diffused to other cutaneous and mucosal tissues. At 3years of age, oral thrush, labial fissures, and cutaneous erythematous desquamating patches developed and have persisted since then. Clinical samples constantly revealed the presence of C.albicans. The clinical diagnosis of familial CMC was posed. The patient received courses of systemic treatment with clotrimazole. However, recurrence of candidiasis occurred shortly after halting antifungal therapy. The patients family included unaffected parents as well as two unaffected brothers and two sisters, while another brother, affected by a severe form of CMC, died when he was 6years old of fulminant hepatitis. At 6years of age, the patient experienced a massive erythematousdesquamating dermatosis involving the face, limbs, nails, and the oral, conjunctival and genital mucosa. In addition, she developed a disfiguring dermatophytosis, caused by Microsporum canis, detected in the squamous samples, restricted to face and scalp (Figure 1(a)). Treatment with clotrimazole and griseofulvine led to a slow, albeit complete, recovery, although she developed alopecia of eyelashs, eyebrows, and scalp. Throughout her life she experienced several recurrent infections by C.albicans, for which she received long-term courses of different antifungals, such as clotrimazole, miconazole, and ketoconazole and as soon as they became available, fluconazole and itraconazole. The therapies with azoles were overall successful to control recurrent candidiasis. Nevertheless, since 2005 a progressive decrease in the susceptibility of C.albicans isolates to azoles, parallel to a worsening of her symptoms, required an increased dosage of these drugs.
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Figure 1: (a) Extensive dermatophytosis, caused by M. canis at 6years of age. (be) Clinical presentation of C.albicans infection at the time of admission: (b) whitish and yellowish plaques on the tongue and perleche, secondary to candidal infection; (c) skin and nail of the right thumb, (d) skin and nails of the feet; (e) endoscopy showing severe esophagitis. (f) Hands and feet after 8months of treatment with oral posaconazole, showing a complete regression of skin and nails candidiasis.
When the patient was admitted to our hospital in June 2009, she presented with an extensive candidiasis of the mouth, hands, and feet (Figures 1(b), 1(c), and 1(d)). In addition, she complained of dysphagia and a weight loss of 10kg in 2months. Specimens from cutaneous, pharyngeal, and buccal swabs were positive for C.albicans, while a nasal swab was negative. In addition to C.albicans, cultures of all specimens grew also Escherichia coli and Enterobacter cloacae. All C.albicans isolates showed the same susceptibility profiles to antifungal drugs, as detected with antimycograms. In particular, they were resistant to nystatin, fluconazole, itraconazole, voriconazole but sensitive to posaconazole, flucytosine, amphotericin B and to echinocandins. Esophagogastroduodenoscopy (EGD) showed an esophageal and duodenal candidiasis (Figure 1(e)). Cancer was excluded by biopsy. Screening investigations including full blood count, routine blood chemistry, C-
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reactive protein, liver function tests, protein electrophoresis, levels of ferritin, urea and electrolytes, IgA, IgG, IgE, IgM, C3, C4. and tests for thyroid, parathyroid, adrenal, and HIV antibodies were performed. Lymphopenia was present (8001,200cells/mm3) with lymphocyte count upon admission of CD45+ 888cells/mm3 (1,6002,400), CD3+ 772cells/mm3 (9602500), CD4+ 484cells/mm3 (5401,400), CD8+ 238cells/mm3(270930), CD19+ 40cells/mm3 (90400), and CD16+56+ 52cells/mm3 (90590). Erythrocyte sedimentation rate was 65mm/hour and all the other laboratory tests were normal, consistent with the clinical presentation of the case. Antinuclear Antibodies (ANAs) were positive, but endocrinopathies or other defined autoimmune diseases were excluded. In particular, we did not find an association between CMC and hypothyroidism. The thyroid function was normal, as determined by the normal values of FT3, FT4 and TSH (4.6pg/mL; 16.3pg/mL and 2.55IU/mL, resp.) and negativity of antithyroid antibodies. Moreover, thyroid physical examination and ultrasonography were normal. The autoimmune polyendocrinopathycandidiasis-ectodermal dystrophy (APECED) [2], common in the Sardinian population [5], was ruled out by genetic analysis of the AIRE gene, that showed a wild-type sequence. Hyper-IgE syndrome was excluded by clinical features [3] and IgE levels were normal (4.63kU/L). HIV infection was ruled out by negative serological and viral RNAbased tests. Diabetes mellitus, neoplasias, immunosuppressive treatments, and other clinical conditions commonly associated with Candida infection were also ruled out. The diagnosis of familial CMC was confirmed and a treatment with amphotericin-B (50mg/day IV) for 2weeks was promptly started for the treatment of severe resistant skin, mouth, and esophageal candidiasis, resulting in an improvement of dysphagia. Orally administered posaconazole (400mg twice per day) replaced amphotericin-B, resulting in a significant regression of the dysphagia as well as a clear improvement of the cutaneous candidiasis after 2weeks of treatment. Onychomycosis regressed partially and more slowly during the following months (Figure 1(f)). After 2months, the dosage of oral posaconazole was reduced to 200mg once a day, without a relapse of clinical symptoms. The therapy was temporarily discontinued after 3months. About 2weeks later, a relapse of candidiasis was observed, although it was limited to the oral mucosa, with no involvement of other sites. Posaconazole was then started again at a dosage of 200mg, three times per day for a month with a 15-day discontinuation. As maintenance therapy, this regimen is being repeated cyclically with no observable side effects.
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Discussion Although CMCs can arise from a variety of clinical conditions, they may disclose rare primary immunodeficiencies, reflecting defects in the first line of host defence against fungi. Interestingly, Glocker et al. [6] and Fewerda et al. [7] recently reported the first monogenetic defects in humans, who presented with the clinical features of CMC and other mycoses, caused by mutations in the genes encoding CARD9 (MIM 607212) and Dectin-1 (MIM 613108). These defects are linked to the role that these proteins play in the activation of the multifaceted Th17 lymphocytes and their production of interleukins (e.g., IL-17 and IL-22) for epithelial host defense against fungal infection. Animal models suggested that, a multipart pathway, starting from the yeast transmembrane pattern recognition receptor Dectin-1 on epithelial cells and phagocytes, leads to the activation of the CARD9 signaling complex that produces cytokines that initiate differentiation of CD4+ T lymphocytes toward the Th17 phenotype, crucial for the adaptive antifungal immunity [8]. In addition, the discovery in humans of autoantibodies against IL-17 and IL-22, as recently observed in APECED [9, 10] further supports the role of Th17 in host defense against Candida. Finally, new evidence supporting the role of IL-22 in protection from candidiasis has been reported [11, 12]. Therefore, impairment of the Th17 lymphocytes and/or their cytokines appears to be the common denominator of genetically heterogeneous but clinically related disorders. CMCs are characterized by persistent refractory/recurrent infections, commonly caused by C.albicans, and occasionally complicated by dermatophytosis [1], and therefore require long-term and extensive antifungal treatment. Until the late 1980s, patients with chronic candidiasis were typically treated only when symptomatic. From the late 1980s, the availability of new azoles (e.g., clotrimazole, ketoconazole, itraconazole and fluconazole) represented a dramatic improvement in the management, prophylaxis, and treatment of these forms of CMC. However, following the use of these drugs, a decrease in the susceptibility of the C.albicans strains to azole antifungals became common and, in the treated patients, the therapeutic response started failing with the consequent development of refractory candidal infections [4]. Other therapeutic options include flucytosine, amphotericin B, and the newest azoles, such as voriconazole and posaconazole, and more recently echinocandins. Different studies have reported successful treatments of CMC caused by azole-resistant isolates of Candida spp., with systemic amphotericin B [1315], voriconazole [16], or echinocandins [17, 18]. In the case of our patient, besides nails, skin, and oral mucosa, an extensive esophageal and duodenal azole-resistant C.albicans infection
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was also present. While topical therapy is ineffective, oral or intravenous azoles represents first-line treatments of these forms [19]. Nevertheless, C.albicans resistant to azoles, including voriconazole, leaves clinicians with few therapeutic options, further limited by toxicity and route of administration. Although amphotericin B or echinocandins are primarily recommended in the treatment of esophageal infection caused by azole-refractory Candida spp.[19], difficulties regarding the intravenous route of administration and/or toxicity, particularly for prolonged use, may be problematic. Among the possible choices, posaconazole has the advantage of being both safe in long-term use and orally administrable [19, 20]. For this reason, we chose to treat our patient with oral posaconazole, even though amphotericin B was promptly administered, given the patients conditions and the time required to obtain posaconazole. The treatment was very well tolerated and brought complete control of the C.albicans in all sites of infection. An intermittent posaconazole administration scheme is currently undergoing, aiming to reduce the relapse rate and, possibly, the risk of resistance. Conclusions Although in the case of our patient a specific genetic explanation for her hereditary primary immunodeficiency cannot yet be offered, posaconazole treatment of the chronic infection sustained by azoleresistant C.albicans was confirmed to be appropriate, given both the patients clinical and microbiological history.
REFERENCES 1. C. H. Kirkpatrick and H. R. Hill, Chronic mucocutaneous candidiasis, Pediatric Infectious Disease Journal, vol. 20, no. 2, pp. 197206, 2001. 2. P. Ahonen, Autoimmune polyendocrinopathy-candidosis-ectodermal dystrophy (APECED): autosomal recessive inheritance, Clinical Genetics, vol. 27, no. 6, pp. 535542, 1985. 3. Y. Minegishi, M. Saito, and M. Saito, Dominant-negative mutations in the DNA-binding domain of STAT3 cause hyper-IgE syndrome, Nature, vol. 448, no. 7157, pp. 10581062, 2007. 4. R. Rautemaa, M. Richardson, M. Pfaller, J. Perheentupa, and H. Saxn, Reduction of fluconazole susceptibility of Candida albicans in APECED patients due to long-term use of ketoconazole and miconazole, Scandinavian Journal of Infectious Diseases, vol. 40, no. 11-12, pp. 904907, 2008. 5. M. C. Rosatelli, A. Meloni, and A. Meloni, A common mutation in Sardinian autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy patients, Human Genetics, vol. 103, no. 4, pp. 428434, 1998. 6. E. O. Glocker, A. Hennigs, and A. Hennigs, A homozygous CARD9 mutation in a family with susceptibility to fungal infections, New England Journal of Medicine, vol. 361, no. 18, pp. 1727 1735, 2009. 7. B. Ferwerda, G. Ferwerda, and G. Ferwerda, Human dectin-1 deficiency and mucocutaneous fungal infections, New England Journal of Medicine, vol. 361, no. 18, pp. 17601767, 2009. 8. S. LeibundGut-Landmann, O. Gross, and O. Gross, Syk- and CARD9-dependent coupling of innate immunity to the induction of T helper cells that produce interleukin 17, Nature Immunology, vol. 8, no. 6, pp. 630638, 2007. 9. A. Puel, R. Dffinger, and R. Dffinger, Autoantibodies against IL-17A, IL-17F, and IL-22 in patients with chronic mucocutaneous candidiasis and autoimmune polyendocrine syndrome type I, Journal of Experimental Medicine, vol. 207, no. 2, pp. 291297, 2010.
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10. K. Kisand, A. S. Be Wolff, and A. S. Be Wolff, Chronic mucocutaneous candidiasis in APECED or thymoma patients correlates with autoimmunity to Th17-associated cytokines,Journal of Experimental Medicine, vol. 207, no. 2, pp. 299308, 2010. 11. A. De Luca, T. Zelante, and T. Zelante, IL-22 defines a novel immune pathway of antifungal resistance, Mucosal Immunology, vol. 3, no. 4, pp. 361373, 2010. 12. W.-F. Ng, A. von Delwig, and A. von Delwig, Impaired TH17 responses in patients with chronic mucocutaneous candidiasis with and without autoimmune polyendocrinopathy-candidiasisectodermal dystrophy, Journal of Allergy and Clinical Immunology, vol. 126, no. 5, pp. 10061015. 13. N. Rosman, Chronic mucocutaneous candidiasis, Postgraduate Medical Journal, vol. 55, no. 647, pp. 611614, 1979. 14. H. W. Waweru and D. M. Owili, Chronic mucocutaneous candidiasis treated with amphotericin B. Case report, East African Medical Journal, vol. 60, no. 8, pp. 588591, 1983. 15. T. C. Dixon, W. J. Steinbach, D. K. Benjamin, L. W. Williams, and L. A. Myers, DisseminatedCandida tropicalis in a patient with chronic mucocutaneous candidiasis, Southern Medical Journal, vol. 97, no. 8, pp. 788790, 2004. 16. Y. Peate, J. Hernndez, B. Hernndez-Machn, D. Islas, A. M. Martn, and L. Borrego, Therapy with voriconazol for a case of chronic mucocutaneous candidiasis, Actas Dermo-Sifiliograficas, vol. 97, no. 10, pp. 679680, 2006. 17. T. Suzuki and A. Imamura, A case of chronic mucocutaneous candidasis cured with micafungin, Kansenshogaku Zasshi, vol. 79, no. 2, pp. 143148, 2005. 18. M. Jayasinghe, S. Schmidt, B. Walker, M. Rcken, and M. Schaller, Successful treatment of azoleresistant chronic mucocutaneous candidosis with caspofungin, Acta Dermato-Venereologica, vol. 86, no. 6, pp. 563564, 2006. 19. P. G. Pappas, C. A. Kauffman, and C. A. Kauffman, Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America,Clinical Infectious Diseases, vol. 48, no. 5, pp. 503535, 2009. 20. I. I. Raad, J. R. Graybill, and J. R. Graybill, Safety of long-term oral posaconazole use in the treatment of refractory invasive fungal infections, Clinical Infectious Diseases, vol. 42, no. 12, pp. 17261734, 2006.
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PROBIOTICS FOR PREVENTION OF RECURRENT VULVOVAGINAL CANDIDIASIS: A REVIEW

SOURCE:http://www.interpharma.co.th/textword/image_upload/Text/Pro5/Probiotic%20for%20preventi on%20of%20recurrent%20vulvovaginal%20candidiasis.pdf AUTHORS: Matthew E. Falagas1,2*, Gregoria I. Betsi1 and Stavros Athanasiou3 - 1Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece; 2Department of Medicine, Tufts University School of Medicine, Boston, MA, USA; 31st Department of Obstetrics and Gynaecology,Athens University School of Medicine, Athens, Greece DATE PUBLISHED: June 21, 2006
Vulvovaginal candidiasis (VVC) is a common infection affecting the quality of life of many women. Probiotics have been investigated as possible agents for the prevention of recurrences of VVC. We reviewed the available literature. In some studies the development of VVC was associated with either a low number of lactobacilli in the vagina or with the presenceofH2O2-nonproducing vaginal lactobacilli, although there are a few studies not supporting these statements. In addition, in vitro studies have shown that lactobacilli can inhibit the growth of Candida albicans and/or its adherence on the vaginal epithelium. The results of some clinical trials support the effectiveness of lactobacilli, especially Lactobacillus acidophilus, Lactobacillus rhamnosus GR-1 and Lactobacillus fermentum RC-14, administered either orally or intravaginally in colonizing the vagina and/or preventing the colonization and infection of the vagina by C. albicans, while the results of a small number of clinical trials do not corroborate these findings. Nevertheless, most of the relevant clinical trials had methodological problems such as small sample size, no control group (placebo) and included women without confirmed recurrent VVC, and thus they are not reliable for drawing definitive conclusions. Thus, the available evidence for the use of probiotics for prevention of recurrent VVC is limited. However, the empirical use of probiotics may be considered in women with frequent recurrence of VVC (more than three episodes per year), especially for those who have adverse effects from or contraindications for the use of antifungal agents, since adverse effects of probiotics are very rare. In any case women should be clearly informed about the unproven usefulness of probiotics for this purpose. In conclusion, despite the promising results of some studies, further research is needed to prove the effectiveness of probiotics in preventing the recurrences of VVC and to allow their wide use for this indication. Keywords: candidal vaginitis, yeast vaginitis, fungal infections, lactobacilli, bifidobacteria
Introduction Vulvovaginal candidiasis (VVC) is a common infection among women that is associated with considerable morbidity and healthcare cost. A survey by Foxman et al.1 in the US showed that 6.5% and 8% of women older than 18 years reported 1 and 4 episodes of VVC during the 2 months and 1 year prior to the survey, respectively. In
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Article 8: Probiotics for Prevention of Reccurent Vulvovaginal Candidiasis: A Review
addition, the total annual cost (in 1995) for dealing with VVC was estimated at $1.8 billion. The high incidence and associated healthcare cost of VVC highlight the need for the development of effective agents for its prevention. Probiotics are defined as live microorganisms which when administered in adequate amounts confer a health benefit on the host.2 There is strong evidence that Lactobacillus rhamnosus GG is effective for the treatment of acute rotavirus diarrhoea in children, causing a significant reduction of its duration.2 In addition, their usefulness for the prevention and/or treatment of many other diseases, such as antibiotic-associated diarrhoea (Saccharomyces boulardii), Helicobacter pylori infections, inflammatory bowel diseases, allergy, cancer, urinary tract infections and bacterial vaginosis, is under research.2 In the present review we tried to compile and summarize the existing data regarding the potential use of probiotics for the prevention of VVC. Many women who suffer from VVC already use these agents without prescription. In a survey carried out by Pirotta et al., 73% of 1117 women in the age range 1870 years self-reported having had symptoms of VVC in the past and 35% reported that these symptoms appeared after an antibiotic course. Lactobacillus products were used by 40% and 43% of these women for prevention and treatment of post-antibiotic vulvovaginitis, respectively.3 It should be mentioned that the names of some lactobacilli strains have changed recently. Lactobacillus acidophilus RC-14 and Lactobacillus fermentum RC-14 studied in the Netherlands and Canada were renamed as Lactobacillus reuteri RC-14 and Lactobacillus casei GR-1 and L. casei var. rhamnosus was renamed as L. rhamnosus GR-1. However, in our review we used the names of lactobacillus strains as they were mentioned in the cited articles. Literature search We searched for articles in the PubMed (19751/2006), from which we also found some additional relevant references. The keywords were vulvovaginal candidiasis, candidal vaginitis, yeast vaginitis, fungal infections, probiotics, lactobacilli, bifidobacteria. We focused on microbiological studies and clinical trials. Specifically, we found relevant information from original articles and reviews regarding the role of endogenous lactobacilli both in normal and in Candida-infected vaginal flora, in vitro experiments investigating the effect of probiotics on the growth and adherence of Candida albicans on the vaginal
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epithelium, human studies examining the ability of orally or intravaginally administered probiotics to prevent recurrent VVCs and adverse effects of probiotics. Vaginal lactobacilli and pathogenesis of VVC Lactobacilli, especially Lactobacillus crispatus,47 Lactobacillus jensenii4,7 and Lactobacillus iners,5,7,8 are most commonly the dominant microorganisms in the vagina of healthy premenopausal women. Lactobacilli produce lactic acid and other substances, which maintain a low pH in the vagina, thus preventing the overgrowth of pathogens, at least those causing bacterial vaginosis (BV) and gonorrhoea. C. albicans may also be found in the vagina of healthy premenopausal women. In a study of premenopausal women by Sobel et al., C. albicans was isolated from 25% of 20 healthy women.9 Although the pathogenesis of VVC remains a controversial issue, it seems that when the balance between the microorganisms existing in the vaginal microbiota is disrupted, the overgrowth of Candida is facilitated. Antibiotic therapy, spermicide use, oral contraceptives, oestrogen therapy, diabetes mellitus, tight clothing and frequent sexual intercourse are factors that increase the risk for development of VVC.10 Women with VVC complain about thick white caseous vaginal discharge and pruritus, and often dyspareunia, vulvar erythema and swelling. Similar symptoms and signs also occur in women with BV, thus leading to frequent misdiagnosis of BV as VVC, especially when it occurs after antibiotic therapy. It has been suggested in some studies that lactobacilli are quite common even in the vaginal epithelium of women with VVC. Sobel et al. found that lactobacilli were the dominant vaginal microorganisms in 90% of 20 healthy premenopausal women and in 96% of 24 premenopausal women with acute exacerbations of recurrent VVC.9 However, the composition of lactobacilli species and/or strains was different between healthy women and those with VVC. The vaginal microbiota of healthy women was more frequently dominated by Lactobacillus salivarius (isolation rate 35%), while the vagina of women with VVC was more commonly dominated by Lactobacillus catenaforme (isolation rate 42%).9 Demirezen et al.11 found that presence of lactobacilli was more common among 59 studied women with VVC than among 391 healthy women. The results of some studies associated VVC either with a reduced number of lactobacilli or with species of lactobacilli not producing H2O2. In a study of 7918 pregnant women, Hillier et al. found that VVC was associated either with normal vaginal microbiota (dominated by lactobacilli) or with intermediate flora (with decreased
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lactobacilli).12 Some other studies suggested that pregnant13,14 or post-term15 women whose vaginas were colonized by H2O2producing lactobacilli were less likely tohave symptomatic VVC than those colonized with H2O2-nonproducing vaginal lactobacilli. However, Hawes et al.16 suggested hat H2O2-producing lactobacilli do not protect against VVC. In a study of 182 women visiting a sexually transmitted disease clinic, 25 of whom developed VVC during a 2 year follow-up, the absence of lactobacilli from the vagina was not found to increase the incidence of VVC. In vitro experiments There are some in vitro experiments which show that some lactobacilli strains can inhibit the adherence and/or the growth of C. albicans. However, these results do not necessarily apply to humans, since the physiological and pathophysiological mechanisms taking place in humans are more complex and cannot be accurately imitated in the laboratory. Osset et al.17 found that 8 of 15 studied lactobacilli inhibited significantly the adhesion of C. albicans Y18 to vaginal cells. They also found that some lactobacilli inhibited the growth of C. albicans Y18 in liquid assays, but not in solid assays. Strus et al.18 found that Lactobacillus delbrueckii, which produces large amounts of H2O2, inhibited the growth of C. albicans more strongly and quickly than many other studied strains isolated from the vaginas of healthy women, while Lactobacillusplantarum, which does not produce H2O2, showed the most prolonged inhibitory activity starting after 24 h. Boris et al.19 found that L. acidophilus, Lactobacillus gasseri and L. jensenii, isolated from the vaginas of healthy premenopausal women, coaggregated in vitro with C. albicans, isolated from the same vaginal samples. The adherence of C. albicans on the vaginal epithelial cells, collected from the same women, was greatly decreased when L.acidophilus was added in comparison with the adherence observed when only Candida was present. Adherence on the vagina is an important virulence factor of C. albicans; thus, reducing its adherence may prevent VVC. Coaggregation of lactobacilli with Candida may also be important for the prophylaxis against vaginal infections by preventing the binding of Candida to the receptors of the vaginal epithelium.19 Some substances produced by specific lactobacilli strains have been found to exert an inhibitory effect upon C. albicans, at least in vitro. Velraeds et al. found that the initial adherence rates of two C. albicans strains, suspended in a urine sample, on a silicone rubber filled with a biosurfactant of L. acidophilus RC-14 (surlactin), 4 h after low urine flow, decreased by 50% compared with the adherence rates on a
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silicone rubber without surlactin, although the numbers of adhering Candida cells were similar between the two rubbers.20 Okkers et al. found that pentocin TV35b, a bacteriocin-like peptide isolated from Lactobacillus pentosus, inhibited the growth of C. albicans.21 Reid et al.22 suggested that a biosurfactant produced by L. fermentum RC-14 inhibits the adhesion of C. albicans. Clinical studies In Table 1 we present some clinical trials that have been conducted in order to evaluate the ability of orally or intravaginally administered lactobacilli to inhibit the vaginal colonization by yeast and prevent the recurrence of VVC. Reid et al.23 reported the case of a 33-year-old woman with recurrent cystitis and VVC (20 episodes of VVC in 30 months), whose vagina was colonized by L. casei var. rhamnosus GR1 up to 7 weeks after the vaginal administration of one pessary of these lactobacilli. The woman had no symptoms of vaginitis during this period and for the next 6 months during which two more pessaries were inserted into her vagina. A clinical trial suggesting the effectiveness of vaginal lactobacilli for the treatment of VVC was conducted by Hilton et al.,24 who administered vaginal suppositories of Lactobacillus GG twice per day for 7 days to 28 women with symptoms and signs of VVC at the start of the study and a history of recurrent VVC (>5 per year). A serious limitation of this study was that only 5 of these women had considerable colonies of C. albicans at the start of the study, maybe because 15 of the studied women had taken antifungal agents just before the study. All of them reported improvement of their vaginal symptoms and were found to have reduced vaginal erythema and discharge during clinical examination. Four of the five women with positive vaginal cultures had negative cultures after receiving lactobacilli. However, no conclusions can be drawn from this study due to its poor design and the small sample of studied women with confirmed VVC. Williams et al.25 also examined the ability of intravaginally administered lactobacilli to reduce the VVC risk in a doubleblind, placebo-controlled trial of 164 HIV-positive women, a group of patients in whom recurrent VVC is common. The women were randomized into three groups: the first group received intravaginally L. acidophilus once per week, the second received vaginal clotrimazole weekly and the third took placebo (control group). During 21 months of the study, 34 cases of VVC were diagnosed clinically and microbiologically. The relative risk of developing VVC was 0.5 for the lactobacilli-treated and 0.4 for the clotrimazole-treated women as
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compared with the control group. Moreover, the median time until the first episode of VVC was longer for women who received lactobacilli than for those who took placebo, but the difference was not statistically significant (P = 0.09). Some other studies have investigated the ability of orally administered lactobacilli to colonize the vagina and/or reduce the vaginal colonization and infection by Candida. Reid et al.26 conducted a randomized trial in 64 healthy women in the age range 1946 years without any urogenital infections in the year prior to the study. For 60 days 32 of the studied women received orally daily L. rhamnosus GR-1 and L. fermentum RC-14, while the other 32 women received placebo. Cultures of the vaginal swabs of the studied women 4 weeks after the administration showed a significant increase in vaginal lactobacilli (P = 0.01) and a significant reduction in yeast (P = 0.01) in the lactobacillitreated compared with the placebo-treated women. In another clinical trial, Reid et al.27 administered L. rhamnosus GR-1 and L. fermentum RC-14 (>109 viable) orally twice daily for 14 days in 10 women with recurrent urogenital infections, 9 of whom had recurrent yeast vaginitis. The vaginal microbiota of 5 of those 9 women with recurrent VVC had <10 colonies or no lactobacilli at the start of the study, while the vaginas of the other 4 women were dominated by lactobacilli. One week after the beginning of the trial, lactobacilli dominated the vagina of all women and GR-1 and/or RC-14 were recovered from all of them. No recurrences of yeast vaginitis appeared during the study and follow-up. Reid et al.28 supported the possible ability of orally administeredL. rhamnosus GR-1 and L. fermentum RC-14 (at a dose of more than 8 108 viable lactobacilli) to restore and maintain a normal vaginal microbiota in a randomized clinical trial in 42 women in the age range 1750 years without symptoms of urogenital infection at the start and during the study, 33 of whom reported a history of VVC. The women were randomly separated into four groups; groups 1, 2 and 3 received daily orally capsules of GR-1/RC-14 at different dosages and group 4 received daily one capsule of L. rhamnosus GG. Of the women who had a normal vaginal microbiota at the beginning of the study, 92% (12/13) of the GR-1/RC-14-treated and 50% (2/4) of the GGtreated remained normal within 28 days. Of the women who had a history of yeast vaginitis in the 5 years prior to the study and an abnormal vaginal microbiota at the start of the study, 54% (7/13) of the GR-1/RC-14treated and 25% (1/4) of the GG-treated developed a normal vaginal microbiota within 28 days. Hilton et al.29 found that L. acidophilus can reduce the vaginal colonization and infection by Candida in a clinical trial in 33 women with recurrent candidal vaginitis (5/year), 13 of whom completed the study. The studied women were randomized into two groups; the first group received daily 8 ounces of yogurt with L.
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acidophilus for 6 months and did not consume any yogurt for the 6 following months, and the other group consumed first the yogurt-free and then the yogurt-containing diet. The mean number of candidal infections and the mean number of candidal colonizations of the vagina and rectum per woman were significantly less during the 6 months of yogurt consumption in comparison with the 6 months without receiving yogurt (0.38 versus 2.54, P = 0.001 and 0.84 versus 3.23, P = 0.001, respectively). However, the fact that the vaginal colonization by Lactobacillus was not statistically significantly increased during yogurt intake and that the studied women were not blinded makes it difficult to interpret the results of this study. On the other hand, there are a few studies that do not support a role for probiotics in the prevention of recurrent VVC. Shalev et al.30 studied 46 women with recurrent vaginitis (4 episodes during the year prior to the study), 18 of whom had VVC and 8 had VVC and bacterial vaginosis. The women were randomized into 2 groups of 23 women; the first group received 150 mL/day yogurt with >108 cfu/mL live L. acidophilus for 2 months and the second group received 150 mL/day of a pasteurized yogurt for the same period. For the next 2 months women of both groups did not consume any yogurt. For the last 2 months of the study the first group consumed pasteurized yogurt and the second group yogurts with lactobacilli. During the first 4 months 28 women took part in the study and only 7 completed the whole protocol. The percentage of women with positive L. acidophilus vaginal cultures among the first group increased after the first 1 and 2 months of the study and was significantly higher than that of the second group. Although a progressive decrease in positive vaginal cultures for Candida was found in both groups, the percentage of women with positive Candida cultures after the first 1 and 2 months of the study was not significantly different between the two groups. However, in this trial no consideration was given to the properties of the tested lactobacillus strain against Candida; thus, it is difficult to draw conclusions regarding the effectiveness of probiotics against VVC. Pirotta et al.31 also did not support the use of combinations of specific lactobacilli, either given orally or intravaginally, for the prevention of post-antibiotic vulvovaginitis. They conducted a randomized, placebocontrolled, double-blind clinical trial in non-pregnant women in the age range 1850 years who received oral powder of L. rhamnosus and Bifidobacterium longum (Lactobac) twice daily and/or one vaginal pessary of L. rhamnosus, L. delbrueckii, L. acidophilus and Streptococcus thermophilus (Femilac) each night and/or oral and/or intravaginal placebo during 6 days of antibiotic administration for a non-gynaecological infection and for 4 days afterwards. Four days after completion of the intervention, post-antibiotic vulvovaginitis had
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developed in 23% (55/235) of the studied women [95% confidence interval (CI) 1829%]. The OR for developing post-antibiotic vulvovaginitis was 1.06, while receiving oral lactobacilli (95% CI 0.58 1.94), and 1.38, while receiving vaginal lactobacilli (95% CI 0.75 2.54), in comparison with placebo. A careful review of the studies investigating the role of probiotics in the prevention of recurrent VVC suggests that most of them have important methodological shortcomings. In the majority of the studies only a small sample of women was included or completed the study.27,29,30 Moreover in most of the studies it was not mentioned whether the reported episodes of recurrent VVC prior to the trials were confirmed by cultures of the vaginal fluids or they were just selfdiagnosed by the studied women.24,2730 Furthermore, there was no control group in some of the studies, so as to compare the women receiving lactobacilli with others receiving placebo.24,27,28 Finally, it is worth mentioning that the studies by Williams et al. and Pirotta et al. did not examine the ability of probiotics to prevent recurrences in women who already had recurrent VVC, but the efficacy of specific probiotics to prevent the development of VVC in women at high risk for such infections, specifically HIV-positive and women receiving antibiotics.25,31 In addition, the study by Reid et al.26 in 2003 addressed the potential effectiveness of two specific lactobacilli to prevent development of VVC in healthy women. Adverse effects of probiotics Probiotics are generally considered to be safe. However, some probiotic species have been rarely isolated from infectious sites. A study showed that only in a mean of 0.2% of positive blood cultures in Finland during 19952000 were Lactobacillus isolates reported.32 Apart from lactobacillaemia, infectious endocarditis,33 liver abscess34 and fungaemia35 are some infections which have been associated with probiotics. These cases appear mainly in patients with serious underlying diseases and/or immunosuppression. 33,36,37 Moreover, only a few cases have been reported, which associate consumed lactobacilli with those isolated from infectious sites.34,38 Generally, the cases of infections associated with probiotics are scarce in comparison with the considerable and gradually increasing consumption of probiotics.32
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Conclusions In conclusion, it is still controversial whether probiotics can prevent recurrences of VVC, while there may be more pathophysiological basis for their effectiveness in the prevention of BV. Lactobacilli have been frequently found to co-exist with Candida in the vaginal epithelium of women with VVC, while they are significantly reduced in women with BV. Some in vitro studies and clinical trials had positive results regarding the effectiveness of some specific lactobacilli strains against C. albicans. However, most of the trials either included a small sample of women or women with no confirmed episodes of VVC or were not placebo controlled. Moreover, there were differences among the trials regarding the strain of the tested probiotic, its dosage and the duration of treatment. It should be emphasized that the various probiotic strains have different properties and different effects on Candida; thus, results from studies testing one strain should not be extrapolated to other strains. Consequently, it is difficult to especially L. acidophilus, L. rhamnosus GR-1 and L. fermentum RC-14, may be considered as potential empirical preventive agents in women who suffer from frequent episodes of VVC (more than three episodes per year), since adverse effects from their use are scarce, especially when the use of antifungal agents is contraindicated or is associated with adverse effects. However, more randomized, double-blind, placebo-controlled trials with a larger sample size should be carried out, so as to clarify whether probiotics can be used effectively and safely for the prophylaxis of recurrent episodes of VVC.
REFERENCES
Foxman B, Barlow R, DArcy H et al. Candida vaginitis: selfreported incidence and associated costs. Amer Sex Transm Dis Assoc 2000; 27: 2305. 2. Reid G, Jass J, Sebulsky T et al. Potential uses of probiotics in clinical practice. Clin Microbiol Rev 2003; 16: 65872. 3. Pirotta M, Gunn J, Chondros P. Not thrush again! Womens experience of post-antibiotic vulvovaginitis. MJA 2003; 179: 436. 4. Antonio M, Hawes S, Hillier S. The identification of vaginal Lactobacillus species and the demographic and microbiologic characteristics of women colonised by these species. J Infect Dis 1999; 180: 19506. 5. Zhou X, Bent SJ. Characterization of vaginal microbial communities in adult healthy women using cultivation-independent methods. Microbiology 2004; 150: 256573. 6. Song Y, Kato N, Matsumiya Y et al. Identification of and hydrogen peroxide production by fecal and vaginal Lactobacilli isolated from Japanese women and newborn infants. J Clin Microbiol 1999; 37: 30624. 7. Vasquez A, Jakobsson T, Ahrne S et al. Vaginal Lactobacillus flora of healthy Swedish women. J Clin Microbiol 2002; 40: 27469. 8. Butron J, Cardieux P, Reid G. Improved understanding of the bacterial vaginal microbiota of women before and after probiotic instillation. Appl Environ Microbiol 2003; 69: 97101. 9. Sobel J, Chaim W. Vaginal microbiology of women with acute recurrent vulvovaginal candidiasis. J Clin Microbiol 1996; 34: 24979. 10. Jeavons H. Prevention and treatment of vulvovaginal candidiasis using exogenous Lactobacillus. J Obstet Gynecol Neonatal Nurs 2003;32: 28796. 11. Demirezen S. The Lactobacilli-Candida relationship in cervicovaginal smears. Cent Eur J Public Health 2002; 10: 979. 1.
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12. Hillier SL, Krohn MA, Nugent RP et al. Characteristics of three vaginal flora patterns assessed by gram stain among pregnant women. Vaginal infections and prematurity study group. Am J Obstet Gynecol 1992; 166: 93844. 13. Hillier SL, Krohn MA, Klebanoff SJ et al. The relationship of hydrogen peroxide-producing lactobacilli to bacterial vaginosis and genital microflora in pregnant women. Obstet Gynecol 1992; 79:36973. 14. Rossel GA, Holst E, Milsom I et al. Fetal fibronectin and microorganisms in vaginal fluid of healthy pregnant women. Acta Obstet Gynecol Scand 1996; 75: 5205. 15. Goffeng AR, Holst E, Nilsson C et al. Microoorganisms in vaginal fluid from women in prolonged pregnancy. Gynecol Obstet Invest 1997; 44: 1620. 16. Hawes SE, Hillier SL, Benedetti J et al. Hydrogen peroxideproducing lactobacilli and acquisition of vaginal infections. J Infect Dis 1996; 174: 105863. 17. Osset J, Garcia E, Bartolome RM et al. Role of Lactobacillus as protector against vaginal candidiasis. Med Clin 2001; 117: 2858. 18. Strus M, Brzychczy-Wloch M, Kucharska A et al. Inhibitory activity of vaginal Lactobacillus bacteria on yeasts causing vulvovaginal candidiasis. Med Dosw Mikrobiol 2005; 57: 717. 19. Boris S, Suarez J, Vazquez F et al. Adherence of human vaginal Lactobacilli to vaginal epithelial cells and interaction with uropathogens. Infect Immun 1998; 66: 19859. 20. Velraeds MM, van de Belt-Gritter B, van der Mei HC et al. Interference in initial adhesion of uropathogenic bacteria and yeasts to silicone rubber by a Lactobacillus acidophilus biosurfactant. J Med Microbiol 1998; 47: 10815. 21. Okkers DJ, Dicks LM, Silvester M et al. Characterization of pentocin TV35b, a bacteriocin-like peptide isolated from Lactobacillus pentosus with a fungistatic effect on Candida albicans. J Appl Microbiol 1999; 87: 72634. 22. Reid G, Bruce AW. Selection of Lactobacillus strains for urogenital probiotic applications. J Infect Dis 2001; 183: S7780. 23. Reid G, Millsap K, Bruce A. Implantation of Lactobacillus casei var rhamnosus into vagina. Lancet 1994; 344: 1229. 24. Hilton E, Rindos P, Isenberg H. Lactobacillus GG vaginal suppositories and vaginitis. J Clin Microbiol 1995; 33: 1433. 25. Williams AB, Yu C, Tashima K et al. Evaluation of two self-care treatments for prevention of vaginal candidiasis in women with HIV. J Assoc Nurses AIDS Care 2001; 12: 517. 26. Reid G, Charbonneau D, Erb J et al. Oral use of Lactobacillus rhamnosus GR-1 and L. fermentum RC14 significantly alters vaginal flora: randomized, placebo-controlled trial in 64 healthy women. FEMS Immun Med Microbiol 2003; 35: 1314. 27. Reid G, Bruce A, Fraser N et al. Oral probiotics can resolve urogenital infections. FEMS Immun Med Microbiol 2001; 30: 4952. 28. Reid G, Beuerman D, Heinemann C et al. Probiotic Lactobacillus dose required to restore and maintain a normal vaginal flora. FEMS Immun Med Microbiol 2001; 32: 3741. 29. Hilton E, Isenberg HD, Alperstein P. Ingestion of yogurt containing Lactobacillus acidophilus as prophylaxis for candidal vaginitis. Ann Intern Med 1992; 116: 3537. 30. Shalev E, Battino S, Weiner E et al. Ingestion of yogurt containing Lactobacillus acidophilus compared with pasteurized yogurt as prophylaxis for recurrent candidal vaginitis and bacterial vaginosis. Arch Fam Med 1996; 5: 5936. 31. Pirotta M, Gunn J, Chondros P et al. Effect of lactobacillus in preventing post-antibiotic vulvovaginal candidiasis: a randomized controlled trial. BMJ 2004; 329: 54852. 32. Salminen MK, Tynkkynen S, Rautelin H et al. Lactobacillus bacteremia during a rapid increase in probiotic use of Lactobacillus rhamnosus GG in Finland. Clin Infect Dis 2002; 35: 115560. 33. Husni RN, Gordon SM, Washington JA et al. Lactobacillus bacteremia and endocarditis: review of 45 cases. Clin Infect Dis 1997; 25: 104855. 34. Rautio M, Jousimies-Somer H, Kauma H et al. Liver abscess due to a Lactobacillus rhamnosus strain indistinguishable from L. rhamnosus strain GG. Clin Infect Dis 1999; 28: 115960. 35. Munoz P, Bouza E, Cuerca-Estrella M et al. Saccharomyces cerevisiae fungemia: an emerging infectious disease. Clin Infect Dis 2005; 40: 162534. 36. Borriello SP, Hammes WP, Holzapfel W et al. Safety of probiotics that contain Lactobacilli or Bifidobacteria. Clin Infect Dis 2003; 36: 77580. 37. Antony SJ, Stratton CW, Dummer S. Lactobacillus bacteremia: description of the clinical course in adult patients without endocarditis. Clin Infect Dis 1996; 23: 7738. 38. Mackay A, Taylor M, Kibbler C et al. Lactobacillus endocarditiscaused by a probiotic organism. Clin Microbiol Infect 1999; 5: 2902.
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PROSPECTS FOR DEVELOPMENT OF A VACCINE TO PREVENT AND CONTROL VAGINAL CANDIDIASIS

SOURCE: http://www.springerlink.com/content/n1568385453l3671/ AUTHORS: Paul L. Fidel Jr., Department of Microbiology, Immunology, and Parasitology, Louisiana State University Health Sciences Center, New Orleans & Jim E. Cutler, Department of Microbiology, Immunology, and Parasitology, Louisiana State University Health Sciences Center, New Orleans, Research Institute for Children, Childrens Hospital, New Orleans. DATE PUBLISHED: November 5, 2010 Abstract
A vaccine against recurrent vulvovaginal candidiasis (RVVC) would benefit a large number of women who suffer from this debilitating syndrome. To date, several antigen formulations have been tested with modest results. In this article, we review the latest vaccine study reported in the literature. The candidate is a -glucan conjugate administered with a human compatible adjuvant. Results in a mouse model of vaginitis were again modest for protection. However, the study included live animal imaging to quantify fungal burden; animals were challenged with a Candida strain carrying a gene encoding a glycophosphatidylinositol (GPI)-linked cell wall protein and luciferase. Fungal burden was expressed as photons following substrate administration. Protection appeared to be mediated by -glucan antibodies. Although modest protection was observed, the imaging system was less variable than semi-quantitative plate counts of vaginal lavage fluid. Despite these advances in evaluating protection, a vaccine candidate against RVVC worthy of clinical testing remains elusive.
Introduction Vulvovaginal candidiasis (VVC) and recurrent VVC (RVVC), caused by Candida species, is a major public health problem affecting a large number of otherwise healthy women of child-bearing age [14]. Although uncomplicated VVC, defined as single episodes with known disposing factors, usually responds to treatment, RVVC cases marked by idiopathic recurrent episodes can be virtually untreatable. Both forms of disease have a significant effect on quality of life and together pose a huge burden to the health care system, which are the driving forces for novel treatment and prevention strategies. To this end, immunotherapies or vaccines against this and other fungal diseases are under investigation [5]. The immune pathogenesis of VVC and RVVC has been intensely studied over the past two decades [622], but the factors associated with resistance and susceptibility have remained largely unknown until recently when reports surfaced revealing a major paradigm change. These studies showed that instead of susceptibility being associated with a local immune deficiency, symptomatic infection in susceptible women results from a response to Candida albicans by vaginal epithelial cells that promotes an aggressive migration of polymorphonuclear neutrophils
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Article 9: Prospects for Development of a Vaccine to Prevent and Control Vaginal Candidiasis
(PMNs) into the vaginal canal. The ensuing acute inflammatory response ultimately causes the symptoms associated with vaginitis, but is nonclearing in that the Candida is unaffected by the inflammatory cells [23]. The vaginal epithelium of women resistant to VVC, on the other hand, does not provoke an inflammatory response upon contact with Candida, thus VVC-resistant women may harbor the fungus, but only in its commensal form. This information highlights the importance of epithelial cells and the innate immune system as being intimately involved in susceptibility or resistance to symptomatic condition. Indeed, it was recently reported through an established animal model of vaginal candidiasis that calcium-binding proteins, S100A8 and S100A9, produced by vaginal epithelial cells following interaction with Candida is the central trigger for the chemotaxis of PMNs into the vaginal cavity [24]. Hence, the new hypothesis is that VVC is associated with signals following Candidavaginal epithelial cell interactions that promote a nonprotective inflammatory PMN response and concomitant clinical symptoms. The amount of Candida present in the vagina is crucial to the epithelial cellmediated signal(s) and this amount can be variable for different groups of women. In effect, the epithelial cells of women are either sensitive or insensitive to Candida and secrete danger signals when the threshold of resistance isbreached. For example, women with RVVC inevitably acquire an infection shortly after completing a regimen of antifungal therapy. Vaginal epithelial cells in these women are extremely sensitive to Candida and signal the PMN infiltration after exposure to very low numbers of the fungus. Vaginal epithelial cells of women with an infrequent history of VVC due to known predisposing factors have a lower sensitivity for Candida and thus do not signal the PMNs until the population numbers of Candida increase following growth-promoting conditions (i.e., antibiotic therapy, hormone replacement therapy, use of highestrogen oral contraceptives, pregnancy, or diabetes mellitus). Vaginal epithelial cells in women with no history of VVC are highly insensitive to Candida. Thus, although the population numbers of Candida can increase under similar conditions, they rarely, if ever, cross a threshold where the epithelial cells will stimulate PMN migration and are spared development of symptoms of vaginitis. The lack of protection by adaptive responses to Candida in the vagina appears to involve strong immunoregulation, as exemplified in infected animals by the presence of TGF-, / T cells, and plasmacytoid dendritic cells [20, 25, 26]. The immunoregulatory factors may well be the result of an evolution of immunity away from responses leading to strong inflammatory reactions to a commensal organism in the reproductive tract. The exception seems to be in the rat model of vaginal candidiasis, where both T and B cells have been implicated in protection against the infection [27, 28] that otherwise clears spontaneously, uncharacteristic of the clinical condition or mouse model. Candida-specific antibodies are detected clinically and can be induced by immunization and antigen administration in animal
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models [2931]. However, little to no Candida-specific antibody has been detected from a vaginal inoculation in the mouse model [32]. Humoral immunity induced as a result of infection is generally not considered protective and may be under some form of immunoregulation as well. However, parenteral immunization with subcellular antigens enriched for Candida cell wall surface mannoproteins may induce protective antibody responses against experimental vaginal infection [33], and monoclonal antibodies against certain mannan components are protective when given intraperitoneally [3335]. Although rapid complement opsonization of the fungal cells with antibody is involved in the mechanism of protection against hematogenously disseminated candidiasis [36], a mechanism by which antibodies protect against vaginal infection is unknown. This topic is further complicated by the finding that antibodies against Candida may be protective, unprotective, and indifferent. Protective antibodies include IgM and IgG3 antibodies in the mouse and IgG2b antibodies in the rat [30, 34, 35]. Based on this information, if a vaccine were to be effective against Candida vaginitis, it would most likely have to be antibody mediated and carefully characterized and confirmed as a protective antibody. The vaccine would function, by mechanisms yet to be defined, to reduce the number of Candida in susceptible women so that the epithelial cell danger signal does not get initiated and the acute inflammatory response causing the symptoms is ablated or avoided. Over the past 15 years, a limited number of reports have been published on vaccination attempts against Candida vaginitis. Most included simple immunization schemes with antigen and adjuvant or vectors as a means to understand the host response rather than test primary vaccine candidates. Antigens included Hsp-90, Als3, - glucan (laminarin), mannoprotein, secreted aspartyl proteases (SAPs), and yeast killer toxin anti-idiotypic antibodies [34, 3739, 40, 41, 42]. Adjuvants or carrier proteins included liposomes, cholera toxin, diphtheria toxoid, and alum. DNA preparations were also attempted. Routes included intravaginal, intradermal, intranasal, and intravenous. Most were performed in the rat model of vaginal candidiasis, which is quite distinct from the mouse model and does not parallel the clinical syndrome. Others were performed in the more clinically relevant mouse model. In any case, some protection was observed, the predominant response being antibody mediated. Recent Vaccine Studies During the past year, there was only one report testing a vaccine candidate against Candida vaginitis in a mouse model. The candidate is a -glucan conjugate vaccine that induces anti-glucan antibodies; the investigators alsoreported on an imaging approach to detect the organism and analyze protection [43]. The -glucan vaccine (laminarin-
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CRM) (obtained from Novartis Vaccines and Diagnostics, Cambridge, MA, but based on earlier studies by this group [41]) was formulated with a human-compatible MF59 adjuvant and administered to mice subcutaneously, followed 14 and 21 days later by booster immunizations intraperitoneally of the vaccine without adjuvant. The mice were then placed into pseudoestrus 3 days later (day 24) and weekly thereafter. On days 30 and 31, the mice were challenged by intravaginal administration of 107 C.albicans CA1398 blastoconidia carrying the reported gene for the fungus, ACT1p-gLUC59 or, simply, gLUC59. This reporter system is based on expression of the C.albicans PGA59 gene that encodes a GPIlinked cell wall protein [44] along with Gaussia princeps luciferase [45], resulting in surface-expressed luciferase on the fungal cells. Following intravginal challenge, the fungal burden may be assessed by intravaginal administration of the luciferase substrate, coelenterazine, which results in photon emission and enables IVIS Imaging System 200 (Caliper Life Sciences, Hopkinton, MA) imaging of such mice under anesthesia. Total photon emission from the vaginal area was captured and quantified with Living Image software (Caliper Life Sciences). In some experiments, vaginal lavages were collected and fungal burden was determined by semi-quantitative plate counts, or vaginae were excised and processed for periodic acid-Schiff staining. Additional experimental designs included passive immunization with vaginal fluids from immunized mice or glucan antibodies. Vaginal lavage fluids were assayed for -glucan antibodies and antibody class by enzyme-linked immune-sorbent assay. The first set of experiments was to confirm that the inoculating strain could be detected by the imaging system and if any protection was achieved. Accordingly, mice were immunized with the vaccine/ adjuvant or adjuvant alone and challenged with the gLUC59 strain or the strain devoid of gLUC59. Over a 25-day period, photons were only detected in the mice challenged with the gLUC59 strain and protection was observed only in vaccinated mice beginning at day 11 post-challenge (Fig. 1). However, the protection was modest, with the greatest differences occurring as a result of seemingly uncharacteristic increases in photon emissions for one or more animals in the adjuvant-only control group compared to the relatively low photon emission by the remaining control animals and all the vaccinated animals. A comparison of results from photon emission and quantitative culture of lavage fluid indicated less variability in the photon analysis. Concurrent protection by both measures of fungal burden was observed only at day 13, even though correlation coefficients ranged from 0.86 to 0.99 on all days. Periodic acid-Schiff staining of tissue sections for day 17 post-challenge showed distinct differences between adjuvant and vaccine-adjuvanttreated mice, but the large differences noted did not match well with the modest differences obtained by imaging and colony-forming unit data. Anti-glucan antibody analyses of serum starting on day 31 showed a greater optical density reading due to IgG antibody in vaccine compared
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to adjuvant-treated mice. The differences between the two groups persisted through day 62 of the experiment, but antibody tittering of the sera was not done at any time point. The same analysis of lavage fluid showed a single spike of IgG in the vaccine-treated mice at day 31 only. Mice given a passive administration of lavage fluid collected 42 days after the first immunization followed by a challenge with the Candida gLUC strain showed a small but significant transient protection (via photon analysis) through 5 days compared to lavage fluid from adjuvant-treated mice. Unfortunately, a critical control showing that the protective factor could be absorbed-out of the fluid by Candida cells was not included. Nonetheless, a similar modest transient protection, as indicated by photon imaging, was observed by passive immunization of an IgG2b monoclonal antibody (mAb2G8) specific for -glucan and previously shown to be protective against candidiasis [41]. Taken together, these results suggest, but do not prove, that protection observed from the lavage fluid was due to anti-glucan antibodies in the lavage fluid. Overall, the authors provide evidence that the imaging system has merits in assessing protection in the mouse model of vaginal candidiasis. The limitation, of course, is the need for a luciferaseexpressing recombinant fungal strain. Importantly, they also provide evidence for protection induced by a -glucan conjugate vaccine. This protection may be mediated by antibody, but further controls and experimentation are necessary to prove this point. Indeed, if antibody is involved in protection, mechanisms by which they protect require investigation. The authors did not detect secretory IgA in vaginal tissue. Instead, they detected IgG that persisted throughout the observational period. Although IgG can be the predominant isotype in the vagina, does IgG prevent an interaction of the fungus with the vaginal epithelium? In interesting previous work, the authors determined that their protective monoclonal antibody, 2G8, which is specific for -1,3-glucan, directly inhibits fungal growth and adherence [46]. It remains to be seen whether such antibodies are produced in response to the vaccine and also somehow show up in vaginal fluid. The authors speculate further that, given the inflammatory response in vaginal tissue during Candida vaginitis, opsonic antibodies also may play a role. However, as indicated earlier in this review, the response of inflammatory cells to the vaginal epithelium not only seems to be ineffective in countering the fungi in the vagina, but may be responsible for disease symptoms. Finally, if a protective antibody response to a vaccine is to be clinically relevant or useful, it must show protection that is durable. A sustained memory cell response needs to be shown in future experiments.
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Conclusions This latest vaccination attempt, like those by previous investigators, showed only modest levels of protection and had limitations both in the experimental approach designed to prove protection due to antibody, and in the imaging system because the method requires a genetically manipulated challenge strain. Intuitively, the modest protectionin the mouse model should preclude clinical trials until a more consistent and effective vaccine formulation is defined. A caveat, however, is that humans may well respond more robustly and effectively than mice against the vaccine, as was the case during development of anticapsular antibodies against Streptococcus pneumoniae (i.e., precursor work to our presentday pneumococcal vaccines). As elucidated so nicely by Casadevall and Scharff [47], early mouse experiments provided, at times, only marginal protection against pneumococcal disease in the mouse, and led some to conclude that antibodies against the bacterium would not be protective in humans. With that in mind, the anti- Candida vaccine described here may be worth putting into human clinical trials, although the argument can always be made for further development. For women susceptible to RVVC, in whom the vaccine likely would be used, a significant and consistent response to Candida exposure would be required to eliminate or reduce the acute inflammatory response initiated by the vaginal epithelium. If mediated by -glucan antibodies, such antibodies would need to be presentcontinuously to respond to a low number of Candida which, in the absence of protective antibodies, can initiate inflammation and, thus, symptoms. Based on these criteria, we predict that this vaccine candidate alone would not be effective in the RVCCsusceptible patient. Indeed, it seems appropriate at this time to promote consideration of a multiple vaccine approach, comprised of one or more vaccine candidates reported by others, including SAPs, mannan, and Als3, among others. Taking into account all the known information presented herein, the million dollar question is: How close are we to a vaccine against Candida vaginitis? Ideally, more research is needed to uncover remaining mysteries in the immunopathogenesis of this disease and any genetic associations. Many of the enigmas have been alluded to above, but if a vaccine will afford protection by antibody, additional questions remain. Which route of administration will be optimal for antibody-mediated disease resistance? How does serum antibody titer relate to protection, and how does antibody from the circulation, especially non-IgA antibody classes, track to the vaginal epithelium? Depending on the mechanism of antibody protection, antibody titer, class or sub-class of antibody produced, and antibody specificity are all important considerations, not only for protection, but also for any deleterious effects on the host. If complement and phagocytic cells are involved in protection, the question remains whether these host factors are present in appropriate amounts and location to effect protection. Some of these issues may be
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circumvented by use of a vaccine that induces antibodies directly cytotoxic for the fungus. However, of fundamental importance is the durability of the host response to the vaccine. Although it is possible that a vaccine can be arrived at empirically, as demonstrated historically for other vaccines, considering the level of current research capability, it is our opinion that answers to many of these fundamental questions should be resolved before embarking on clinical trials.
REFERENCES 1. Sobel JD, Faro S, Force R, et al.: Vulvovaginal candidiasis: Epidemiologic, diagnostic, and therapeutic considerations. Am J Obstet Gynecol 1998, 178:203211. 2. Sobel JD: Pathogenesis and epidemiology of vulvovaginal candidiasis. Ann N Y Acad Sci 1988, 544:547557. 3. Sobel JD: Pathogenesis and treatment of recurrent vulvovaginal candidiasis. Clin Infect Dis 1992, 14:S148S153. 4. Fidel PL Jr, Sobel JD: Immunopathogenesis of recurrent vulvovaginal candidiasis. Clinical Microbiol Rev 1996, 9:335 348. 5. Cutler JE, Deepe GS, Jr, Klein BS: Advances in combating fungal diseases: vaccines on the threshold. Nat Rev Microbiol 2007, 5:1328. 6. Witkin SS: Inhibition of Candida-induced lymphocyte proliferation by antibody to Candida albicans. Obstet Gynecol 1986, 68:696699. 7. Hobbs JR, Briden D, Davidson F, et al.: Immunological aspects of candidal vaginitis. Proc R Soc Med 1977, 70:1114. 8. Fong IW, McCleary P, Read S: Cellular immunity of patients with recurrent or refractory vulvovaginal moniliasis. Am J Obstet Gynecol 1992, 166:887890. 9. Mendling W, Koldovsky U: Investigations by cell-mediated immunologic tests and therapeutic trials with thymopentin in vaginal mycoses. Infect Dis Obstet Gynecol 1996, 4:225231. 10. Fidel PL, Jr, Lynch ME, Redondo-Lopez V, et al.: Systemic cellmediated immune reactivity in women with recurrent vulvovaginalcandidiasis (RVVC). J Infect Dis 1993, 168:14581465. 11. Fidel PL, Jr, Lynch ME, Sobel JD: Effects of preinduced Candidaspecific systemic cell-mediated immunity on experimental vaginalcandidiasis. Infect Immun 1994, 62:10321038. 12. Fidel PL, Jr, Lynch ME, Conaway DH, et al.: Mice immunized by primary vaginal C.albicans infection develop acquired vaginalmucosal immunity. Inf Immun 1995, 63:547553. 13. Hector RF, Domer JE, Carrow EW: Immune responses to Candida albicans in genetically distinct mice. Infect Immun 1982, 38:10201028. 14. Fidel PL, Jr, Lynch ME, Sobel JD: Circulating CD4 and CD8 T cells have little impact on host defense against experimental vaginal candidiasis. Infect Immun 1995, 63:24032408. 15. Black CA, Eyers FM, Dunkley ML, et al.: Major histocompatibility haplotype does not impact the course of experimentally induced murine vaginal candidiasis. Lab Animal Sci 1999, 49:668672. 16. Black CA, Eyers FM, Russell A, et al.: Increased severity of Candida vaginitis in BALB/c nu/nu mice versus the parent strain is not abrogated by adoptive transfer of T cell enriched lymphocytes. J Reprod Immunol 1999, 45:118. 17. Nawrot U, Grzybek-Hryncewicz K, Zielska U, et al.: The study of cell-mediated immune response in recurrent vulvovaginal candidiasis [In Process Citation]. FEMS Immunol Med Microbiol 2000, 29:89 94. 18. Corrigan EM, Clancy RL, Dunkley ML, et al.: Cellular immunity in recurrent vulvovaginal candidiasis. Clin Exp Immunol 1998, 111:574578. 19. Fidel PL, Jr, Luo W, Steele C, et al.: Analysis of vaginal cell populations during experimental vaginal candidiasis. Infect Immun 1999, 67:31353140.
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Candidiasis Mucosal

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Candidiasis Mucosal

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2011

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Amphotericin B deoxycholate Liposomal amphotericin B

5 g at bedtime x 3 days 5 g once

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Tioconazole 6.5% cream Terconazole 0.4% cream

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0.8% cream 80-mg suppositories

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