Treatment of Esophageal Candidiasis

First-Line Treatment Options

The American College of Physicians recommends fluconazole (100 mg/day orally for 14-21 days) as the first-line treatment for esophageal candidiasis, due to its high efficacy and good tolerability 1, 2
The Infectious Diseases Society of America suggests that oral itraconazole solution (200 mg/day for 14-21 days) is an equally effective alternative, although with lower tolerability 1, 2

The Centers for Disease Control and Prevention states that a definitive diagnosis requires endoscopic visualization of lesions with histopathological demonstration of characteristic Candida yeast forms in tissue and confirmation by culture 3

The American College of Physicians recommends that esophageal candidiasis refractory to fluconazole should be treated with itraconazole solution (>200 mg/day orally) 1, 2
For patients who do not respond to itraconazole, amphotericin B intravenously (0.3-0.7 mg/kg/day) can be used 1, 2
Caspofungin, micafungin, or anidulafungina are reasonable alternatives for refractory cases 4

The Centers for Disease Control and Prevention notes that response to treatment is usually rapid, with improvement in signs and symptoms within 48-72 hours 5
Patients treated for more than 7-10 days with azoles may experience hepatotoxicity, and periodic monitoring of liver function should be considered if prolonged therapy (>21 days) is anticipated 5

The Infectious Diseases Society of America recommends that suppressive therapy should be used occasionally in patients with recurrent, debilitating infections 1, 2
To reduce the likelihood of developing antifungal resistance, suppressive therapy should only be used if recurrences are frequent or debilitating 2, 6
In patients with advanced HIV, recurrent infections are common, and long-term suppressive therapy with fluconazole is effective in preventing recurrences 4

The American College of Physicians notes that ketoconazole and itraconazole capsules are less effective than fluconazole due to variable absorption 1, 2
In patients with HIV, the use of antiretroviral therapy has been associated with a decrease in the frequency of oropharyngeal and esophageal candidiasis, and should be used as adjunctive therapy whenever possible 4