Opportunistic fungal infections in patients with acquired immune deficiency syndrome

The recently developed antifungal agents itraconazole and fluconazole have been evaluated for primary and maintenance therapy for mycoses in patients with acquired immune deficiency syndrome (AIDS) in comparative and non-comparative trials. In oropharyngeal candidosis, ketoconazole may have to be given at a dose of 400 mg/day for comparable efficacy with fluconazole, 50 mg/day, because many patients with AIDS lack the gastric acid secretion necessary for drug absorption. Relapse rates were high. Itraconazole, 200 mg/day for 4 weeks, was as effective as ketoconazole, 400 mg/day, in achieving clinical remission and was better tolerated, but relapse rates were also high. An oral formulation of itraconazole in cyclodextrin has given clinical and mycological remissions in 39/39 patients after 7 days of treatment. In primary treatment of cryptococcosis, fluconazole is well tolerated, but is effective in only 50% of patients. Pilot studies of itraconazole, 200-400 mg/day, gave responses in 11/12 patients, of whom 8 had meningitis. Itraconazole combined with flucytosine gave a response in 12/13 patients, of whom 9 had meningitis. This combination shortened the time to cure. Both itraconazole and fluconazole are effective as maintenance therapy given after successful primary therapy of cryptococcosis. Itraconazole, 200 mg/day, was successful in preventing relapse in 34/39 patients over a mean 12-month period. The serum antigen titre fell progressively in 14, and fell to zero in 18 patients. Limited non-comparative trials suggest that triazoles are effective in coccidioidomycosis, and in particular that itraconazole is active against histoplasmosis in patients with AIDS; 8/9 patients with histoplasmosis responded to itraconazole, 400 mg/day, with a mean follow-up of 1 year.(ABSTRACT TRUNCATED AT 250 WORDS)