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Palliative cancer care - oral problems - Management
How should I manage oral Candida infection?
- Manage predisposing local and systemic risk factors for oral Candida infection in conjunction with anticandidal treatment.
- In immunocompetent people:
- Topical nystatin, or miconazole is recommended as first-line treatment.
- Oral fluconazole is recommended for persistent candidiasis that does not respond to topical treatment.
- In immunocompromised people, high-dose oral fluconazole is generally preferred for first-line treatment.
- Chlorhexidine should be used to clean dentures, and it may be used as an adjunct to topical or oral treatment.
Clarification / Additional information
- The choice of anticandidal drug treatment may be dictated by local policy or based on advice from a local microbiologist.
- People should be advised to keep the drug formulation in contact with the oral mucosal surface for as long as possible by:
- Holding the formulation in the mouth for as long as possible before swallowing.
- Avoiding eating or drinking for 30 minutes after each dose [Regnard and Hockley, 2004].
- When using topical preparations, removing dentures before each administration [Twycross and Wilcock, 2001].
- Oral antifungals are reserved for widespread (e.g. evidence of oesophageal candidiasis) or severe infection, or when topical anticandidals are not tolerated or are ineffective:
- Ketoconazole is less commonly used, following the Committee on Safety of Medicines (CSM) advice that it should not be used for superficial fungal infections because of rare reports of liver damage [CSM, 1983; CSM, 1984].
- Itraconazole is an alternative, but it is less suitable for people at high risk of heart failure. Reports of heart failure have been rare, but the risk seems to be higher in elderly people, people with cardiac disease, people taking negative inotropic drugs (e.g. calcium-channel blockers), and people taking high doses or receiving longer treatment courses [CSM, 2001].
- Dentures should be removed at least once a day and the underside cleaned to remove any adherent infected debris [Twycross and Wilcock, 2001]. For maximum patient comfort, dentures should be rinsed under running water after every meal and the lining of the mouth should be checked for food debris, and dentures left out overnight [Davies and Finlay, 2005].
- Nystatin and chlorhexidine mouthwash should not be used at the same time, as they will inactivate each other. They should be used 1 hour apart.
- Thirty minutes must also be left between the use of toothpaste and chlorhexidine mouthwash [Kinley, Personal Communication, 2007].
Basis for recommendation
- These recommendations represent the general consensus from palliative care resources and local guidelines written by experts on the basis of experience of clinical practice [Twycross and Wilcock, 2001; Twycross et al, 2002; Doyle et al, 2004; Fife Area Drug & Therapeutics Committee, 2004; Lothian Palliative Care Guidelines Group, 2004; Regnard and Hockley, 2004; Davies and Finlay, 2005; Pan-Glasgow Palliative Care Algorithm Group, 2005; DynaMed, 2006; WeMeReC, 2006].
- From an evidence-based perspective:
- Few trials have compared the use of topical anticandidal treatments in people with cancer in palliative care [Pankhurst, 2005].
- A Cochrane review investigated treatment of oral candidiasis in people with cancer receiving treatment and found that evidence about the clinical effects of oral antifungals was insufficient to make strong recommendations for patient care [Clarkson et al, 2004].
- Resistance to nystatin is uncommon although resistance to miconazole is becoming increasingly common, especially in people who are immunocompromised [Davies and Finlay, 2005].
- Mouthwashes are licensed for treatment of oral candidiasis:
- However, apart from their use in disinfecting dentures, evidence is insufficient to recommend their sole use for treating oral candidiasis.
- The adjunctive use of chlorhexidine in oral candidiasis produces varying degree of success [Ellepola and Samaranayake, 2001]. The available evidence about the clinical effects of oral antifungals is insufficient to make strong recommendations for patient care [Clarkson et al, 2004].
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