LETTER
Weekly Fluconazole for Preventing Mucosal Candidiasis in HIV Infection
Guy Baily, MB, MRCP
15 December 1997 | Volume 127 Issue 12 | Page 1131
TO THE EDITOR:
Schuman and colleagues [1] studied low-dose fluconazole (200 mg weekly) as secondary prophylaxis of mucosal candidiasis in HIV-infected women. Although their study was longer than most prospective studies done in this area, their results should not be used to support the widespread use of this regimen as they recommend. We have been here before. When fluconazole first became available, studies in HIV-infected men similarly showed that prophylaxis was effective in reducing relapses of oropharyngeal candidiasis over the short term. As a result, continuous use of low-dose fluconazole became a common and routine treatment in many HIV treatment centers. With time, patients (who started therapy when they were relatively well) became progressively more immunodeficient and cumulative fluconazole exposure increased. After 4 years of this practice, fluconazole-resistant Candida albicans, previously a rarity, became a major clinical problem, affecting up to 10% of patients in some units [2]. Although several factors are implicated, previous fluconazole exposure is strongly associated with the development of resistance [2, 3]. Evidence suggests that low-dose prophylaxis (<100 mg/d) is more likely to lead to resistance than is higher-dose prophylaxis [4] or intermittent treatment [5].
It will be unfortunate if HIV-infected women cannot gain from experience already acquired in men. Despite the short-term benefit that Schuman and colleagues showed, there is every reason to believe that women who receive long-term, low-dose fluconazole therapy and whose underlying HIV disease progresses will be at high risk for resistant candidiasis. This condition may be difficult to manage. Topical treatments and short, higher-dose courses of fluconazole therapy (
100 mg/d; 500-mg total dose) should be the preferred management strategy for as long as possible. If frequent relapse makes continuous therapy desirable, higher doses should be preferred.
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Author and Article Information
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St. Bartholomew's Hospital; London, United Kingdom
1. Schuman P, Capps L, Peng G, Vazquez J, El-Sadr W, Goldman AI, 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.
2. Baily GG, Perry FM, Denning DW, Mandal BK. Fluconazole resistant candidosis in an HIV cohort. AIDS. 1994; 8:787-92.
3. Maenza JR, Keruly JC, Moore RD, Chaisson RE, Merz MG, Gallant JE. Risk factors for fluconazole-resistant candidiasis in human immunodeficiency virus-infected patients. J Infect Dis. 1996; 173:219-25.
4. Heald AE, Cox GM, Schell WA, Bartlett JA, Perfect JR. Oropharyngeal yeast flora and fluconazole resistance in HIV infected patients receiving long-term continuous versus intermittent fluconazole therapy. AIDS. 1996; 10:263-2.
5. Johnson EM, Warnock DW, Luker J, Porter SR, Scully C. Emergence of azole drug resistance in Candida species from HIV-infected patients receiving prolonged fluconazole therapy for oral candidosis. J Antimicrob Agents Chemother. 1995; 35:103-14.
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