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Fluconazole-Resistant Oesophageal Candidiasis — SCE Infectious Diseases MCQ

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ModerateHIV MedicineFluconazole-Resistant Oesophageal CandidiasisSCE Infectious Diseases

A 40-year-old man with advanced HIV (CD4 30) develops oesophageal candidiasis that fails to respond to Fluconazole 200 mg daily for 14 days. Culture from oesophageal brushings grows Candida albicans with Fluconazole MIC 64 mg/L (resistant). What is the most appropriate alternative treatment?

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Correct answer: C — IV Caspofungin 70 mg loading then 50 mg daily (or IV Micafungin 150 mg daily)

Fluconazole-resistant Candida albicans oesophagitis in advanced HIV requires treatment with an echinocandin (Caspofungin or Micafungin IV). Echinocandins are fungicidal against Candida and are effective regardless of azole resistance mechanism. Increasing Fluconazole dose is unlikely to overcome high-level resistance (MIC 64 mg/L). Nystatin has minimal systemic absorption and is insufficient for oesophageal disease. IV Amphotericin B is an alternative but more toxic. ART remains the cornerstone of long-term management.

Reference: BHIVA 2022 – OI guidelines; IDSA 2016 – Candidiasis