Oesophageal candidiasis

Oesophageal candidiasis should be suspected in immunocompromised patients who present with oesophageal symptoms. A diagnostic trial of antifungal therapy may be appropriate in patients with oropharyngeal candidiasis and oesophageal symptoms before investigation with upper gastrointestinal endoscopy and endoscopic biopsy.

Oesophageal candidiasis is uncommon in immunocompetent patients; it is important to exclude immune disorders in patients presenting with oesophageal candidiasis. In particular, oesophageal candidiasis is an indicator condition for HIV testing1. If oesophageal candidiasis is identified, offer HIV testing, regardless of whether the patient has behavioural or epidemiological risk factors for HIV infection.

Patients with undiagnosed HIV infection may present initially with oesophageal candidiasis. In patients who need to be started on therapy for HIV, see Oesophageal candidiasis in adults with HIV infection for advice on starting antiretroviral therapy. Oesophageal candidiasis is uncommon in immunocompetent patients; it is important to exclude immune disorders (eg HIV) in patients presenting with oesophageal candidiasis.

For management of oesophageal candidiasis in adults with HIV infection, see Oesophageal candidiasis in adults with HIV infection.

For immunocompetent patients with asymptomatic oesophageal candidiasis, nystatin liquid can be considered.

For patients with symptomatic oesophageal candidiasis or immunocompromised patients without HIV infection, use:

fluconazole 200 mg (child: 6 mg/kg up to 200 mg) orally for the first dose, then 100 mg (child: 3 mg/kg up to 100 mg) daily for 14 to 21 days. For dosage adjustment in adults with kidney impairment, see fluconazole dosage adjustment. candidiasis, oesophageal fluconazole    

If the patient is unable to tolerate oral therapy, use fluconazole intravenously.

If there is no response to fluconazole, use:

1 itraconazole liquid 200 mg (child: 5 mg/kg up to 200 mg) orally, daily for 14 days2 candidiasis, oesophageal itraconazole    

OR (for adults)

2 posaconazole liquid 400 mg orally with fatty food or an acidic beverage, 12-hourly for 14 days3 candidiasis, oesophageal posaconazole    

OR

2 voriconazole 200 mg orally, 12-hourly for 14 days candidiasis, oesophageal voriconazole voriconazole voriconazole

OR

2voriconazole 200 mg intravenously, 12-hourly for 14 days. For dosage adjustment in adults with kidney impairment, see voriconazole intravenous dosage adjustment. voriconazole voriconazole voriconazole

In cases of clinical treatment failure, take specimens (eg oral scrapings, oesophageal biopsies) for culture before starting second-line therapy, as azole-resistant yeast can occur. Alternatives for patients with confirmed or suspected infection with azole-resistant Candida species include amphotericin B or an echinocandin (eg anidulafungin, caspofungin).

For recurrent infection in adults, consider suppressive therapy with fluconazole (100 to 200 mg orally or intravenously, three times weekly).

1 Indicator conditions for HIV testing are conditions that are seen in people with HIV infection (including undiagnosed infection), conditions that share a transmission route with HIV (eg sexually transmissible infections), or conditions for which management is altered in people with HIV infection (eg tuberculosis).Return
2 Oral preparations of itraconazole are not bioequivalent; appropriate dosing and administration depends on the preparation.Return
3 Oral preparations of posaconazole are not bioequivalent; appropriate dosing and administration depends on the preparation.Return