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A topical antifungal medication in immunocompromised patients
LETTERS TO THE EDITOR
A topical antifungal medication in immunocompromised patients To the Editor: We read with great interest the June 2002 article “Fluconazole mouthrinses for oral candidiasis in postirradiation, transplant, and other patients,” by Epstein et al (2002;93:631-5). We would like to comment on the topical antifungal treatment for stomatitis caused by yeast and mold in immunocompromised patients. We noticed that neither identification of Candida species nor the susceptibility of these isolates to fluconazole were mentioned in the article. In general, Candida albicans and C dubliniensis are the most common species causative of Candida stomatitis, and most isolates are susceptible to fluconazole.1 However, the frequency of oral candidiasis due to other speciesnamely C glabrata, C tropicalis, and C krusei-has also increased, and these species tend to be less susceptible to fluconazole.1 Therefore, when selecting fluconazole mouthrinses as a topical antifungal treatment for oral candidiasis, the potential sensitivity or resistance of Candida species to the drug should be taken into consideration. Basically, it appears that topical therapy with fluconzaole may be effective in treating oral candidiasis caused by C albicans and C dubliniensis, given the early presumptive identification of Candida species by means of CHROMagar Candida.1,2 In contrast to oral candidiasis, in which the causative organisms are detected in the superficial layers of the oral mucosa, filamentous fungi such as Aspergillus species, Exophiala species, and Trichoderma species induce a deep necrotic ulcer in the oral mucosa, advancing relentlessly to cause destruction of alveolar bone and facial muscles in a rapid manner.4,5 For invasive stomatitis due to filamentous fungi, extensive surgical debridement is often useful in combination with systemic antifungal treatment, since topical antifungal treatment is not effective in immunocompromised patients.3,4 In conclusion, it should be noted that in future large controlled studies, identification of pathogenic Candida species and determination of their susceptibility to fluconazole are needed to evaluate the clinical efficacy of fluconazole mouthrinses for oral candidiasis.
Yoshinari Myoken, DDS, PhD Tatsumi Sugata, DDS, PhD Yoshinori Fujita, DDS, PhD Department of Oral Surgery Hiroshima Red Cross and Atomic Bomb Survivors Hospital Hiroshima, Japan Yuzuri Mikami, PhD Research Center for Pathogenic Fungi and Microbial Toxicoses Chiba University, Chiba, Japan Takeshi Kiriyama, DDS, PhD Department of Oral Surgery Hiroshima Prefectural Hospital Hiroshima, Japan REFERENCES 1. Martinez M, Lopez-Rigot JL, Kirkpatrick WR, Coco BJ, Bachmann SP, Patterson TF. Replacement of Candida albicans with C. dubliniensis in human immunodeficiency virus-infected patients with oropharyngeal candidiasis treated with fluconazole. J Clin Microbiol 2002;40:3135-9. 2. Odds FC, Bernaerts R. CHROMagar Candida, a new differential isolation medium for presumptive identification of clinically important Candida species. J Clin Microbiol 1994;32:1923-9. 3. Myoken Y, Sugata T, Kyo T, Fugihara M, Kohara T, Katsu M, et al. Invasive Aspergillus stomatitis in patients with acute leukemia: report of 12 cases. Clin Infect Dis 2001;33:1975-80. 4. Myoken Y, Sugata T, Mikami Y. Infection due to non-Aspergillus fungi in immunocompromised patients receiving itraconazole. Clin Infect Dis 2002;35:494-5. doi:10.1067/moe.2003.101
In reply: We thank Drs Myoken, Sugata, and Mikami for their comments concerning our article on fluconazole mouthrinses for oral candidiasis. The purpose of our trial was to explore the potential use of a topical antifungal application in patients with oral candidiasis. There are limitations in the currently available topical agents, and new formulations and agents are required. The observations of Drs Myoken, Sugata, and Mikami are appropriate, and readers should be aware of the potential resistance to therapy with any antimicrobial agent including antifungal agents, as well as the potential limitations of the agent chosen. Fluconazole is not indicated in a number of fungal infections, including aspergillosis and coccidioidomycosis. We agree
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY April 2003 381
A topical antifungal medication in immunocompromised patients To the Editor: We read with great interest the June 2002 article “Fluconazole mouthrinses for oral candidiasis in postirradiation, transplant, and other patients,” by Epstein et al (2002;93:631-5). We would like to comment on the topical antifungal treatment for stomatitis caused by yeast and mold in immunocompromised patients. We noticed that neither identification of Candida species nor the susceptibility of these isolates to fluconazole were mentioned in the article. In general, Candida albicans and C dubliniensis are the most common species causative of Candida stomatitis, and most isolates are susceptible to fluconazole.1 However, the frequency of oral candidiasis due to other speciesnamely C glabrata, C tropicalis, and C krusei-has also increased, and these species tend to be less susceptible to fluconazole.1 Therefore, when selecting fluconazole mouthrinses as a topical antifungal treatment for oral candidiasis, the potential sensitivity or resistance of Candida species to the drug should be taken into consideration. Basically, it appears that topical therapy with fluconzaole may be effective in treating oral candidiasis caused by C albicans and C dubliniensis, given the early presumptive identification of Candida species by means of CHROMagar Candida.1,2 In contrast to oral candidiasis, in which the causative organisms are detected in the superficial layers of the oral mucosa, filamentous fungi such as Aspergillus species, Exophiala species, and Trichoderma species induce a deep necrotic ulcer in the oral mucosa, advancing relentlessly to cause destruction of alveolar bone and facial muscles in a rapid manner.4,5 For invasive stomatitis due to filamentous fungi, extensive surgical debridement is often useful in combination with systemic antifungal treatment, since topical antifungal treatment is not effective in immunocompromised patients.3,4 In conclusion, it should be noted that in future large controlled studies, identification of pathogenic Candida species and determination of their susceptibility to fluconazole are needed to evaluate the clinical efficacy of fluconazole mouthrinses for oral candidiasis.
Yoshinari Myoken, DDS, PhD Tatsumi Sugata, DDS, PhD Yoshinori Fujita, DDS, PhD Department of Oral Surgery Hiroshima Red Cross and Atomic Bomb Survivors Hospital Hiroshima, Japan Yuzuri Mikami, PhD Research Center for Pathogenic Fungi and Microbial Toxicoses Chiba University, Chiba, Japan Takeshi Kiriyama, DDS, PhD Department of Oral Surgery Hiroshima Prefectural Hospital Hiroshima, Japan REFERENCES 1. Martinez M, Lopez-Rigot JL, Kirkpatrick WR, Coco BJ, Bachmann SP, Patterson TF. Replacement of Candida albicans with C. dubliniensis in human immunodeficiency virus-infected patients with oropharyngeal candidiasis treated with fluconazole. J Clin Microbiol 2002;40:3135-9. 2. Odds FC, Bernaerts R. CHROMagar Candida, a new differential isolation medium for presumptive identification of clinically important Candida species. J Clin Microbiol 1994;32:1923-9. 3. Myoken Y, Sugata T, Kyo T, Fugihara M, Kohara T, Katsu M, et al. Invasive Aspergillus stomatitis in patients with acute leukemia: report of 12 cases. Clin Infect Dis 2001;33:1975-80. 4. Myoken Y, Sugata T, Mikami Y. Infection due to non-Aspergillus fungi in immunocompromised patients receiving itraconazole. Clin Infect Dis 2002;35:494-5. doi:10.1067/moe.2003.101
In reply: We thank Drs Myoken, Sugata, and Mikami for their comments concerning our article on fluconazole mouthrinses for oral candidiasis. The purpose of our trial was to explore the potential use of a topical antifungal application in patients with oral candidiasis. There are limitations in the currently available topical agents, and new formulations and agents are required. The observations of Drs Myoken, Sugata, and Mikami are appropriate, and readers should be aware of the potential resistance to therapy with any antimicrobial agent including antifungal agents, as well as the potential limitations of the agent chosen. Fluconazole is not indicated in a number of fungal infections, including aspergillosis and coccidioidomycosis. We agree
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY April 2003 381