A systematic review of the effectiveness of antifungal drugs for the prevention and treatment of oropharyngeal candidiasis in HIV-positive patients

Objective. A systematic review of randomized clinical trials published betw een 1966 and April 2000 was undertaken to determine the strength of evidenc e for the effectiveness of antifungal drugs (nystatin, clotrimazole, amphot ericin B, fluconazole, ketoconazole, and itraconazole) to prevent and treat oral candidiasis in human immunodeficiency virus-positive patients. Study design. An automated database search identified 366 articles. Six met inclusion and exclusion criteria with respect to prophylaxis; 12 met crite ria for treatment of oral candidiasis. Results. The evidence for the prophylactic efficacy of fluconazole is good, although insufficient to draw conclusions about the other antifungals. Evi dence for treatment effectiveness is insufficient for amphotericin B but go od for nystatin, clotrimazole, fluconazole, ketoconazole, and itraconazole. Conclusion. Suggestions for strengthening the evidence base include the fol lowing: use of larger, more well-defined groups; control for immunologic st atus, viral load, history of oral candidiasis, past exposure to antifungals , baseline oral Candida carriage, drug interactions, and antiretroviral the rapy; and consistent use of compliance monitors, fungal speciation, and sus ceptibility testing.