Fluconazole Prophylaxis in HIV Disease, Revisited

Goldman et al. [ 1] approach the question of emerging drug resistance associated with ongoing fluconazole prophylaxis for mucosal candidal infection in HIV disease. After a median of ~2 years of follow-up, the proportion of oropharyngeal and/or esophageal infections that were clinically refractory or resistant to fluconazole was higher among patients receiving continuous fluconazole therapy (9%) than among those receiving episodic fluconazole therapy (2%), but the risk of any infection was 4 times greater in the latter group. As a result, the risk of a clinically refractory or resistant oropharyngeal and/ or esophageal candidal infection was essentially the same in both groups, at slightly more than 4%. The median MICs of fluconazole increased 2-fold in the episodic fluconazole arm and 3-fold in the episodic fluconazole arm, but many of these patients were receiving treatment for several years. These results, coupled with the fact that there is no general risk to microbial ecology from the use of fluconazole, indicate that concern about resistance should not be a factor in the decision to provide prophylaxis. With this new information, and because