Case 1 Revisited: Avoiding unnecessary Antifungals – Part 2
Avoiding unnecessary antifungalsMr 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.
- 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
- 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.
- 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
The Role of Antifungal Stewardship
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