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HIV + candidiasis Flashcards

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1
Q

Candida can cultured what which body sites?

A

ORAL cavity
GASTROINTESTINAL tract
GENITAL tract

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2
Q

What proportion of the general population have candida species as a commensal organism?

A

75%

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3
Q

What impact does HIV have on the rate of commensal candida prevalence?

A

HIGHER rates

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4
Q

What is the main pathological manifestation of candida in PLW HIV?

A

Mucosal candidiasis

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5
Q

Which mucosal candidiasis is most common in PLW HIV?

A

OROPHARYNGEAL

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6
Q

What proportion of PLW HIV prior to HAART availability experienced oropharyngeal candidiasis?

A

80-90%

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7
Q

What impact does HIV have on the likelihood of vulvovaginitis from candida?

A

similar to immunocompetent people

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8
Q

Which candida species is the most common cause of candida infection?

A

candida ALBICANS

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9
Q

What increases the risk of NON-ALBICANS candida species in PLW HIV?

A

previous AZOLE therapy

advanced IMMUNOSUPPRESSION

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10
Q

What proportion of candida species are NON-ALBICANS in PLW HIV?

A

30%

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11
Q

Name THREE NON-ALBICANS species of candida?

A

1) GLABRATA
2) KRUSEI
3) DUBLINESIS

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12
Q

Which candida species has INTRINSIC azole RESISTANCE?

A

candida KRUSEI

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13
Q

Through what mechanism does AZOLE resistance develop in candida species?

A 
INTRINSIC resistance
or  
recurrent DRUG EXPOSURE
or
combination of above
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14
Q

What species of candida is inherently multi drug resistant and can be a cause of candidaemia?

A

candida AURIS

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15
Q

What does the immunological response involve against candida species?

A 
T helper(Th) 17 T cells
at
gastronintestinal MUCOSA
or 
SKIN
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16
Q

What impact does HIV have on Th17 T cells?

A

disproportionately DEPLETED
early stages of HIV-associated T cell decline
disrupts host SURVEILLANCE
causing PATHOGENICITY

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17
Q

How long do PLW HIV show impaired T cell response to candida after starting treatment?

A

over TWO (2) years

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18
Q

What other clinical factor or patient demographic increases risk of oropharyngeal candidiasis in PLW HIV?

A

PWID

TB

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19
Q

Do candida species thrive in an acidic or alkaline environment?

A

ACIDIC

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20
Q

What is oropharyngeal candidiasis a predictor of in PLW HIV?

A

worsening IMMUNODEFICIENCY

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21
Q

From onset of oropharyngeal candidiasis, what is the time to development of AIDS in PLW HIV?

A

25 months

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22
Q

What are the various oral presentations of oral candidiasis?

A

ERYTHEMATOUS (red patches + depapillation tongue)
HYPERPLASTIC (white plaques, cannot scrape away)
ANGULAR CHEILITIS

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23
Q

What are the typical symptoms of oropharyngeal candidiasis?

A

ASYMPTOMATIC

SORE mouth or throat

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24
Q

What respiratory symptoms are associated with oropharyngeal candidiasis?

A

increased PHLEGM
chronic COUGH
HOARSENESS

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25
Through what mechanisms can GORD and oesophageal candidiasis co-exist?
GORD increased ACIDIC environment candida THRIVE in acidic environment mucosal DAMAGE from GORD candida INVADES more easily
26
What symptoms are associated with EROSIVE oesophagitis in PLW HIV?
HEARTBURN | ACID REGURGITATION
27
What features of dysphagia should raise the suspicion of oesophageal carcinoma in PLW HIV?
no response to CANDIDA treatment | WEIGHT LOSS
28
What clinical risk factors increase risk of oesophageal cancer?
GORD heavy ALCOHOL use SMOKING
29
Does oesophageal candidiasis occur without oropharyngeal candidiasis?
NOT typically may be more likely if on ART should look for other causes of GI symptoms
30
What is the sensitivity of clinical diagnosis of oropharyngeal candidiasis vs microbiological detection?
SIMILAR | therefore clinical diagnosis is sufficient
31
Why are empiric or prophylactic antimicrobials not recommended in candida prevention in PLW HIV?
promote RESISTANCE
32
When is candida culture indicated in oropharyngeal candidiasis?
PERSISTING signs or symptoms despite anti fungal | RECURRENT infection
33
Why is candida culture indicated for persisting or recurrent candida infection?
identify AZOLE -resistant infection
34
As an alternative to swabbing a lesion for investigation of mucosal candidiasis what else can be performed?
oral or vaginal RINSE
35
What is the most common medium for culturing candida species?
BLOOD agar
36
What does the presence of candida in blood culture always indicate?
INVASIVE disease | candidaemia
37
When is endoscopy indicated in oesophageal candidiasis?
TREATMENT FAILURE NO OROPHARYNGEAL infection ALTERNATIVE diagnosis is suspected
38
What is NON-PHARMACOLOGICAL management of oropharyngeal candidiasis?
good ORAL HYGIENE | regular REMOVAL or oral BIOFILM
39
What feature of the oral biofilm affects treatment of oropharyngeal candidiasis?
inherently resistant to azoles
40
What preparation of pharmacological treatment is most effective at treating oropharyngeal candidiasis?
ORAL fluconazole c/w topical therapy
41
What dose treatment is recommended for FIRST episode OROPHARYNGEAL candidiasis?
Fluconazole 100mg DAILY for 7 days
42
When is a higher or longer course of fluconazole indicated for treatment of oropharyngeal candidiasis?
SEVERE or RELAPSED disease
43
What step up regimen is indicated for oropharyngeal candidiasis if first line treatment does not work?
INCREASE dose and duration | Fluconazole 200mg, 7-14 days
44
What are the disadvantages of topical therapy for oropharyngeal candidiasis?
SLOWER clearance of yeast higher RELAPSE rate reduced TOLERABILITY
45
When can topical therapy be used for treatment of oropharyngeal candidiasis?
MILD infection no recurrence fluconazole intolerance
46
What is the typical topical therapy used in oropharyngeal infection?
NYSTATIN (100 000units/mL)
47
What is the regimen for nystatin in oropharyngeal candidiasis?
5ml (5 drops) FOUR (4) times a day | 7-14 days
48
What other topical agents can be used in oropharyngeal candidiasis?
Amphotericin | Clotrimazole
49
What agent can be used to disrupt the oral biofilm formation in oropharyngeal candidiasis?
0.2% CHLORHEXIDINE mouthwash
50
What group of people are at increased risk of oral biofilm formation?
DENTURE wearers
51
Which TWO agents can be used to treat OESOPHAGEAL candidiasis?
FLUCONAZOLE | ITRACONAZOLE
52
What is the typical regimen for OESOPHAGEAL candidiasis?
Fluconazole 200-400mg DAILY | 14-21 days
53
In mild oesophageal candidiasis, what is the recommended regimen with fluconazole?
Fluconazole 200mg | 14 days
54
Why is fluconazole the preferred option over itraconazole for treatment of oesophageal candidiasis?
better BIOAVAILABILITY | less Drug-drug interactions
55
What preparation of itraconazole should be used for oesophageal candidiasis?
oral SOLUTION
56
Why is oral solution preparation of itraconazole recommended if used for oesophageal candidiasis?
better BIOAVAILABILITY
57
What factors affect absorption of itraconazole in PLW HIV?
low CD4 cell | ANTACID preparations
58
What alteration to proton pump inhibitors (PPI) should be made when treating with fluconazole for oesophageal candidiasis?
WITHOLD whilst treatment for ACUTE or SEVERE candidiasis (PPI can inhibit activity of fluconazole)
59
If a person requires acid suppression therapy but ideally would withold PPI for treatment of oesophageal candidiasis, what is an alternative?
switch to SHORTER-acting treatment | H2 antagonist - RANITIDINE
60
Through what pathway is itraconazole metabolised?
cytochrome P450 enzymes
61
Due to its metabolism which drugs should itraconazole not be administered with?
ENZYME-inducing - RIFAMYCINS
62
What is the benefit of fluconazole metabolism if requiring to coadminister with enzyme inducers?
excreted in urine UNCHANGED | not effected by enzyme inducers
63
What is the alternative class of drugs for treatment of oesophageal candidiasis in people with HIV and liver disease?
ECHINOCANDIN
64
When can oral suspension of itraconazole or posaconazole be used for treatment of oropharyngeal candidiasis?
fluconazole RESISTANCE
65
What monitoring is required for people on AZOLEs?
regular LIVER FUNCTION tests
66
What azole regimen does not require liver function monitoring?
LOW-DOSE fluconazole (100mg daily or less)
67
Which azole should be avoided in CONGESTIVE HEART FAILURE?
ITRACONAZOLE
68
When is therapeutic drug monitoring indicated in treatment of oropharyngeal candidiasis?
non-fluconazole agents ITRACONAZOLE, POSACONAZOLE, VORICONAZOLE variable bioavailability
69
Considering various azoles for oesophageal candidiasis, which order should they be used when considering efficacy and toxicity?
``` FLUCONAZOLE ITRACONAZOLE POSACONAZOLE ISAVUCONAZOLE VORICONAZOLE ```
70
If azoles cannot be used for oesophageal candidiasis what classes can be used?
ECHINOCANDINS FUNGINS (caspofungin, micafungin, anidulafungin) IV amphotericin B
71
Which FUNGIN has a comparable efficacy to fluconazole for treatment of oesophageal candidiasis?
MICA-FUNGIN
72
What is the summarised approach to FLUCONAZOLE-REFRACTORY/NON-SUSCEPTIBLE oropharyngeal or oesophageal candidiasis?
``` try ITRACONAZOLE then alternative AZOLE then ECHINOCANDIN ```
73
What is the first line treatment for vulvovaginal candidiasis in PLW HIV?
CLOTRIMAZOLE pessary 500mg
74
If evidence of severe vulvovaginal candidiasis what additional step can be taken?
repeat FLUCONAZOLE oral 72 hours later
75
If recurrent vulvovaginal candidiasis what is the recommended regimen?
Fluconazole 150mg every 72 hours (THREE doses) then WEEKLY for 6 months
76
What is the recommended treatment for vulvovaginal non-albicans candida if reduced fluconazole susceptibility?
NYSTATIN 100 000units PESSARY nightly | 14 days
77
What alternative treatments to nystatin can be used for non-albican vulvovaginal candidiasis?
5-flucytosine (vaginal cream) + nystatin amphotericin pessary boric acid
78
Can fluconazole be used as continuous therapy to reduce recurrence of oropharyngeal or oesophageal candidiasis?
possible no increase in treatment--refractory disease not recommended
79
What is the difference in dosing of fluconazole for oropharyngeal vs oesophageal candidiasis?
ORAL - 100-200mg daily | OESOPHAGEAL - 200-400mg daily
80
ITRACONAZOLE dosing for oropharyngeal or oesophageal candidiasis?
ITRACONAZOLE 200mg TWICE daily (oral SOLUTION)
81
POSACONAZOLE dosing for oropharyngeal or oesophageal candidiasis?
POSACONAZOLE 400mg TWICE daily then 400mg DAILY oral SUSPENSION
82
ISAVUCONAZOLE dosing for oropharyngeal or oesophageal candidiasis?
``` ISAVUCONAZOLE 200mg LOADING dose then 100mg DAILY or 400mg LOADING then 400mg WEEKLY ```
83
What ART can antifungal AMPHOTERICIN interact with?
Tenofovir disoproxil
84
What ART can antifungal CASPOFUNGIN interact with?
Efavirenz | Nevirapine
85
What ART can antifungal FLUCONAZOLE interact with?
``` zidovudine nevirapine rilpivirine cobicistat tenofovir alafanemide ```
86
What ART can antifungal ISAVUCONAZOLE interact with?
tenofovir alafanemide Efavirenz lopinavir/ritonavir etravirine
87
What ART can antifungal ITRACONAZOLE interact with?
``` ritonavir or cobicistat etravirine, efavirenz, nevirapine maraviroc rilpivirin tenofovir alafanemide ```
88
What ART can antifungal POSACONAZOLE interact with?
cobicistat efavirenz rilpivirin ATAZANAVIR
89
What ART can antifungal VORICONAZOLE interact with?
``` efavirenz etravirine lopinavir/ritonavir rilpivirine cobicistat ```
90
What effect does FLUCONAZOLE have on ZIDOVUDINE, NEVIRAPINE, RILPIVIRINE?
INCREASED levels
91
What effect does COBICISTAT have on FLUCONAZOLE?
INCREASED levels
92
Which ART classes commonly have drug-drug interaction with AZOLES?
NNRTI | boosted PIs

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