Opportunistic candidal infections in patients infected with human immunodeficiency virus: prevention issues and priorities.

Mucosal candidiasis (oropharyngeal, esophageal, and vulvovaginal candidiasis) has been among the most prominent opportunistic infections in persons infected with human immunodeficiency virus (HIV). Esophageal candidiasis, an AIDS-defining illness, accounted for 15% of the AIDS-defining illnesses in adults and adolescents diagnosed in the United States through 1992. The diagnosis of oropharyngeal and vaginal candidiasis is based on clinically consistent signs and symptoms and a positive culture or a positive gram, KOH, or calcofluor stain, whereas the diagnosis of esophageal and pulmonary candidiasis is based on histopathology. Although a prospective controlled trial showed that prophylaxis with fluconazole can reduce the risk of mucosal candidiasis in patients with advanced HIV disease, routine primary prophylaxis is not recommended because of the effectiveness of therapy for acute disease, the low mortality associated with mucosal candidiasis, the potential for development of drug-resistant candidal infection, and the cost of prophylaxis. The probability of recurrences increases as CD4 counts decline. Nonetheless, many experts do not recommend chronic prophylaxis to prevent recurrent oropharyngeal and vulvovaginal candidiasis, for the same reasons that primary prophylaxis is not recommended. However, if recurrences are frequent or severe following documented esophageal candidiasis, long-term suppressive therapy with fluconazole should be considered.