Empiric Antifungal Therapy

Given the prevalence of Candida esophagitis in AIDS, empiric antifungal therapy is widely prescribed for symptomatic patients. A prospective randomized trial comparing endoscopy with empiric fluconazole in HIV-infected patients with esophageal symptoms demonstrated a high response rate and substantial cost savings with flucona-zole, and no patient failing empiric therapy developed complications before definitive endoscopic examination (Wilcox et al, 1996). Although not critically studied, an empirical approach is commonly employed in other immunocompromised patients. If patients do not improve rapidly following empiric therapy, I do not recommend additional empiric trials, such as with antiviral therapy. Similarly, immunosuppressed transplant patients who develop esophageal symptoms while already receiving prophylactic antimicrobial therapy, warrant endoscopic examination rather than additional empiric trials or radiological studies. This is particularly true if the patient is receiving cyclosporine, given the many drug interactions with this agent.

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