Oropharyngeal candidiasis: a new treatment option.

In this issue of Clinical Infectious Diseases, Vazquez et al. [1] demonstrate in a well-conceived and well-conducted multicenter trial that posaconazole is equivalent in efficacy to fluconazole in the treatment of oropharyngeal candidiasis in HIV-infected patients. Patients given posaconazole also experienced fewer clinical relapses of oro-pharyngeal candidiasis than did patients given fluconazole. Does this mean that physicians should prescribe posaconazole to treat oropharyngeal candidiasis once the drug is approved by the US Food and Drug Administration? Or, more generally, what is the perspective from which a cli-nician should evaluate these results? Oropharyngeal candidiasis is the current term used to describe disease of the linings of the oral cavity caused almost always by Candida albicans. Disease caused by Candida species, including oropha-ryngeal candidiasis, encompasses a broad spectrum, from the trivial to the most life-threatening of infections. Because the fungus is believed to reside in low numbers on mucous membranes in the healthy host, disease is attributable to a reduction in host defenses, and the host response depends in great measure on where lesions arise. For example, in the most common presentation of oropha-ryngeal candidiasis, pseudomembran-ous candidiasis (the type studied by Vaz-quez and colleagues), Gram staining of the curd-like lesions on buccal membranes demonstrates a tangle of oral bacteria, proliferating fungus (predom-inately blastoconidia and pseudohy-phae), and polymorphonuclear leuko-cytes in an eosinophilic background. Other forms of oropharyngeal candi-diasis manifest as glossitis or erythema in the fissures of the mouth or beneath denture plates. Because the HIV pandemic is raging worldwide, oropharyngeal candidia-sis must be reckoned as one of the most common diseases among humans. It is a sensitive and specific indicator of diminished numbers of CD4 + cells and heralds the onset of significant immune deficiency in people with HIV. For example, 128% of the first 500 patients visiting an HIV clinic in Ho Chi Minh City, Viet-nam, had oropharyngeal candidiasis at the first or second visit, and 21% had pulmonary tuberculosis (with a median CD4 + cell count of 73 cells/mL for all patients) (unpublished data). Moreover, relapse of oropharyngeal candidiasis in patients undergoing HAART is a reliable indicator of drug noncompliance and, hence, worsening immune function. Table 1 lists the range of drugs for treatment of oropharyngeal candidiasis when the objective of treatment is to eliminate signs and symptoms of the disease and to prevent recurrences [2]. Fluconazole is rightfully the standard with which all other antifungal drugs should be compared …