Case 1 Revisited: Avoiding unnecessary Antifungals – Part 2

On further questioning, Mr Daniels gives us more information about his symptoms. He was fully compliant with antifungal treatment but less can be said for his oral hygiene. The problem is visible on inspection. He wears a full upper denture and most days, cleans them only by rinsing under running water. Otherwise, he wears them throughout the day.

He also reports persistent “acid reflux” symptoms at the back of his throat. This is worse after heavy meals or drinking alcohol. In fact, he is currently drinking three or four cans of beer per night (due to stress at work).

Both poor dentition and GORD (gastro-oesophageal reflux disease) are known risk factors for oral candidosis.

Avoiding unnecessary antifungals

Mr Daniels may well require a further antifungal course to resolve his symptoms this time. However, if we do not address the underlying problems, he will need more in the future. As we have covered in Week 3, repeated use of antifungals can increase resistance over time.

His first visit was a missed opportunity to approach these issues. He may never have developed recurrent symptoms with these under control. If we can prevent future antifungal courses by addressing these problems, then failing to do so will lead to unnecessary antifungal treatment.

Dentition

• Bacteria and Candida are normal mouth flora and they form sticky biofilms, dental plaque, on teeth and dentures if not removed by brushing.
• It is well known that biofilm infections cannot be managed with antimicrobials alone. If only antifungals are used for treatment, the benefit is doomed to be short-lived and/or partial.
• Improving Mr Daniels’ denture hygiene will be key to reducing future infections

GORD

• Commensal organisms (like Candida in the mouth) usually only overgrow when the conditions suit this. Candida thrives in an acidic nutrient-rich environment.
• Therefore, if much acid and other stomach contents reach the patient’s oropharynx regularly, this can lead to overgrowth and infection (oral candidosis)
• Lifestyle measures (diet, alcohol) or medications (proton pump inhibitors) will reduce the amount of this acid, and the likelihood of future Candida infections.

Antifungal resistance

• Repeated exposure to antifungals will increase the risk of resistance.
• If he continues to have oral thrush despite the measures above, he may have developed a resistant Candida infection
• In this situation, an oral swab for fungal culture and antifungal susceptibility testing would be recommended
• Continuing with an ineffective antifungal is certainly unnecessary antifungal use

Clinical guidelines are widely available for treatment of oral candidosis. Their use can improve decision making and ensure that repeated antifungal treatments are not the only management option. The guideline from the United Kingdom’s NICE (National Institute of Clinical Excellence) demonstrates this well. Please note that this site is only available to users in the UK.

Revisit Step 3.6, “What Can Be Done?”. Have a think about how these strategies might improve antifungal use in this scenario. You may be able to think of your own approach. Feel free to share your thoughts in the comment section below.