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Weekly Fluconazole for Preventing Mucosal Candidiasis in HIV Infection
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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.
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
