While receiving the intermittent or continuous therapy that is required to treat relapses of oropharyngeal candidiasis, as many as 5% to 10% of patients with advanced human immunodeficiency virus (HIV) infection develop an infection that is clinically or microbiologically resistant to 100 to 200 mg of fluconazole per day [1]. Fluconazole is now available in a suspension of 10 or 40 mg/mL, and we hypothesized that the high salivary levels that are associated with use in a swish-and-swallow format [2] might overcome resistance in some patients.

Patient 1 was a 43-year-old man who had a recent CD4⁺ T-cell count of 7 cells/mm³ and a history of several opportunistic infections. The patient presented in July 1996 with recurrent oropharyngeal candidiasis that had been refractory to 10 days of therapy with fluconazole tablets (200 mg daily). His symptoms resolved while he received fluconazole suspension at 100 mg twice daily, although a few white plaques that yielded Candida organisms remained in his oropharynx (Table 1).

Patient 2 was a 36-year-old man who had a recent CD4⁺ T-cell count of 4 cells/mm³ and a history of several opportunistic infections. The patient presented in September 1996 with relapsing oropharyngeal candidiasis that was refractory to 10 days of therapy with fluconazole tablets (200 mg daily). Symptoms immediately resolved when the patient began receiving fluconazole suspension at 100 mg twice daily, and Candida organisms could no longer be cultured from his oropharynx (Table 1).

These two HIV-infected patients had oropharyngeal candidiasis that was unresponsive to fluconazole and that responded rapidly to a change in fluconazole therapy from tablets to suspension. Patient 1 was infected with microbiologically resistant (minimal inhibitory concentration >64 µg/mL) Candida organisms, and his response was characterized by persistent asymptomatic (but visible) oropharyngeal disease. Patient 2 was infected with microbiologically susceptible Candida organisms and was apparently not responding to therapy because of an inadequate immune response. Both patients complied with therapy, and neither was taking rifampin. At least in some patients, fluconazole suspension taken in a swish-and-swallow format may be a convenient approach to the treatment of oropharyngeal candidiasis that is unresponsive to fluconazole tablets.