Effect of antifungal treatment on the prevalence of yeasts in HIV-infected subjects

Oral Candida albicans strain diversity and maintenance in HIV positive women in South Africa

OBJECTIVE

This study investigated C. albicans strain diversity and maintenance in the oral cavity of HIV positive women over a 6 month period.

STUDY DESIGN

C. albicans strains were isolated from 17 HIV positive women at Charlotte Maxeke Academic Hospital, Johannesburg at 3 intervals over a 6 month period. Strains were genotyped using ABC and Multilocus Sequence Typing (MLST) techniques. In the MLST technique, for each strain, a Diploid Sequence Type (DST) number was obtained. Using cluster analysis, an Unweighted Pair Group Method with Arithmetic Mean (UPGMA) dendrogram and a matrix of strain similarities were generated. Strains were also compared to the previous South African isolates documented in the MLST database.

RESULTS

Ninety four percent of women carried the same ABC genotype for 6 months. MLST technique, showed that ten women (58.8%) carried the same DST at 2 visits, while seven (41.2%) carried different DST at all visits. Further analysis showed that 64.7% of women were recolonised with different strains and 35.3% carried the same strains of C. albicans with heterozygosity. A total of 40 diploid sequence types were identified of which 27 DSTs were unique to this study group that were added to the MLST database. Most of the strains were closely related to previously isolated strains from South Africa.

CONCLUSION

Recolonization of the oral cavity with different strains and microevolution of the original strains of C. albicans can occur, which can be a potential problem for HIV patients, in whom highly virulent and drug resistant strains can emerge.

The Role of Host and Fungal Factors in the Commensal-to-Pathogen Transition of Candida albicans

Abstract

Purpose of Review

The fungus Candida albicans has evolved to live in close association with warm-blooded hosts and is found frequently on mucosal surfaces of healthy humans. As an opportunistic pathogen, C. albicans can also cause mucosal and disseminated infections (candidiasis). This review describes the features that differentiate the fungus in the commensal versus pathogenic state and the main factors underlying C. albicans commensal-to-pathogen transition.

Recent Findings

Adhesion, invasion, and tissue damage are critical steps in the infection process. Especially invasion and damage require transcriptional and morphological changes that differentiate C. albicans in the pathogenic from the commensal state. While the commensal-to-pathogen transition has some conserved causes and features in the oral cavity, the female urogenital tract, and the gut, site-specific differences have been identified in recent years.

Summary

This review highlights how specific factors in the different mucosal niches affect development of candidiasis. Recent evidence suggests that colonization of the gut is not only a risk factor for systemic candidiasis but might also provide beneficial effects to the host.

Oral Cavity and Candida albicans: Colonisation to the Development of Infection

Candida colonisation of the oral cavity increases in immunocompromised individuals which leads to the development of oral candidiasis. In addition, host factors such as xerostomia, smoking, oral prostheses, dental caries, diabetes and cancer treatment accelerate the disease process. Candida albicans is the primary causative agent of this infection, owing to its ability to form biofilm and hyphae and to produce hydrolytic enzymes and candialysin. Although mucosal immunity is activated, from the time hyphae-associated toxin is formed by the colonising C. albicans cells, an increased number and virulence of this pathogenic organism collectively leads to infection. Prevention of the development of infection can be achieved by addressing the host physiological factors and habits. For maintenance of oral health, conventional oral hygiene products containing antimicrobial compounds, essential oils and phytochemicals can be considered, these products can maintain the low number of Candida in the oral cavity and reduce their virulence. Vulnerable patients should be educated in order to increase compliance.

Epidemiology and Prevalence of Oral Candidiasis in HIV Patients From Chad in the Post-HAART Era

Oral candidiasis remains a common problem in HIV-infected individuals, especially in sub-Saharan Africa. Here, we performed the first study in Chad on the prevalence of oral yeasts carriage and oral candidiasis in HIV-positive subjects from southern Chad and analyzed the influence of HAART, CD4⁺ T-cell numbers, and antimycotics in 589 patients. These patients were recruited from a specialized medical center for HIV patients in Sarh and from a rural medical health dispensary in the vicinity, including a total of 384 HIV-positive and 205 HIV-negative individuals. Yeasts obtained from oral specimen were identified by MALDI-TOF MS and their antifungal susceptibility profiles determined. The overall prevalence of yeast colonization and symptomatic oral candidiasis in HIV-infected patients was 25.1%. The prevalence of oral candidiasis was higher in untreated than in HAART-treated HIV-positive patients (16% vs. 2%; p < 0.01). Oral candidiasis was furthermore associated with high fungal burdens of Candida albicans and a CD4⁺ T-cell number <200/μl. A shift toward non-albicans Candida species was observed under nucleoside-based HAART therapy. Azole antifungal drug resistance was only observed for the intrinsically resistant species Candida krusei and Candida glabrata. Prevalence of oral candidiasis in the studied area was very low. The species distribution was similar to other countries around the world, with C. albicans being dominant. Candida dubliniensis was not isolated. Nucleoside-based HAART therapy significantly reduced oral colonization as well as occurrence of oral candidiasis caused by C. albicans and led to a species shift toward non-albicans species. Antifungal resistance was not yet a concern in Chad.

HPLC-MS identification and expression of Candida drug-resistance proteins from African HIV-infected patients

The objective of this study was to elucidate the proteomic mechanisms of drug resistance in HIV-infected African patients. Cell membrane fractions from forty oral Candida isolates isolated from African HIV-positive patients were analysed using HPLC-MS with the aim of identifying proteins associated with their pathogenicity and drug resistance. Heat shock proteins that mediate the fungicidal activity of salivary peptides were found in all tested Candida fractions, with pH-responsive proteins associated with increased pathogenicity only being present in the three most commonly isolated species. ABC multidrug transporter efflux pumps and estrogen binding proteins were only found in C. albicans fractions, while ergosterol biosynthesis proteins were identified in four species. The combination of various adherence, invasion, upregulation and efflux pump mechanisms appear to be instrumental for the Candida host colonization and drug resistance emergence in HIV-infected individuals.

Quantification of Oral Candidal Carriage Rate and Prevalence of Oral Candidal Species in HIV Patients with and Without Highly Active Antiretroviral Therapy

BACKGROUND

Most documents review decrease in the prevalence of HIV related oral lesions to the tune of 10-50% following the advent of HAART. However long term use of HAART on oral health status of HIV infected subjects is poorly documented. Also antifungal agents can effectively treat mucosal candidiasis. However their use can lead to colonization with less susceptible strains among normal susceptible strains.

AIMS AND OBJECTIVES

To know the candidal carriage rate (i.e. presence/absence of candidal growth), candidal density(CFUs/ml) & species variations (species diversity) in HIV positive individuals with and without highly active anti-retroviral therapy (HAART), attending the regional voluntary Counselling and Confidential Testing Centre (VCCTC).

MATERIALS AND METHODS

The study population were categorized into 3 groups. Method followed were Germ tube test, Chlamydospore formation test, CHROM-Agar test.

RESULTS

Quantification comparison study of candidal carriage rate, density with detection of various candidal species in the oral cavity of HIV-positive individuals with and without HAART therapy was conducted.

CONCLUSION

HIV positive individuals with HAART therapy treatment prooved higher candidal carriage rate and lower density than Non-HAART category.

Quantitative Analysis of Selected Microorganisms Present at Various Sites in a Prosthetics Clinic and Dental Laboratory during Complete Denture Fabrication

Background: Contamination with oral commensals and pathogenic microorganisms, and cross contamination between clinic and laboratory can occur. The amount of contamination has not been determined. Methods: Samples from different clinical and laboratory stages before and after disinfection (17 sites, 10 samples per stage) were collected. Laboratory surfaces and equipment were swabbed for 10 days (11 sites). Swabs were cultured for total mixed flora, Streptococci, Lactobacilli, Staphylococcus aureus, aerobic Gram-negative bacteria (AGNB) and Candida. Knowledge of infection control among staff and students was assessed. Results: Clinic: In total, 30–40% of the samples overall were contaminated with mixed flora and Streptococci of >100 cfu/swab; >100 cfu of AGNB and Candida were present on 6% and 1% of samples; 2% contained <100 cfu of S. aureus. Laboratory: In total, 17–48% of the samples overall were contaminated with mixed flora and Streptococci of >100 cfu/swab; >100 cfu of AGNB were present on 11% of samples; none contained >100 cfu of Candida. Disinfection significantly reduced the level of all organisms. Knowledge of infection control was sufficient, but compliance was poor. Conclusion: Although the count of mixed flora was high, potential pathogens such as S. aureus and Candida were low. In immunocompromised patients, this can become a problem.

Oral candidal carriage correlates with CD4+ cell count but not with HIV and highly active antiretroviral therapy status

AIM

The occurrence of oropharyngeal candidiasis (OPC) may be influenced by oral candidal carriage (OCC). Although OPC is strongly associated with low CD4⁺ cell count (400-700 cells/mm³ ) and a lack of highly active antiretroviral therapy (HAART), the effect of these two parameters on OCC is debatable. We investigated the oral candidal carriage, species diversity, antifungal susceptibility and the association of OCC with CD4⁺ cell count and HAART.

METHODS

Oral candidal isolates from 120 HIV⁺ patients (60 receiving and 60 not receiving HAART) and 60 healthy controls were quantified, and their species determined using standard culture and biochemical methods, followed by antifungal susceptibility testing using the agar dilution method.

RESULTS

The OCC was significantly higher in HIV⁺ patients; Candida albicans was the most frequently isolated species in both groups, followed by Candida tropicalis. Candidal density carriage correlated significantly with CD4⁺ cell count, but not with HIV and HAART status. Among the isolates from HIV⁺ patients, 35.4% showed reduced susceptibility to fluconazole.

CONCLUSION

HIV status results in significantly elevated rates of OCC C albicans remains the predominant pathogen, although other species are emerging rapidly. Resistance to fluconazole is on the rise, and more efficient treatment strategies need to be implemented.

K21 Compound, a Potent Antifungal Agent: Implications for the Treatment of Fluconazole-Resistant HIV-Associated Candida Species

Background/Objectives: With mucocutaneous candidiasis being highly prevalent in HIV patients, the emergence of fluconazole-resistant Candida species forms a major challenge in treating and eradicating these infections. The objective of this study was to establish the antifungal activity of K21, a membrane-rupturing antimicrobial compound derived from a silica quaternary ammonium compound (SiQAC) with tetraethoxysilane (TEOS). Methods: The study sample included 81 Candida species of which 9 were type strains and 72 were clinical isolates. Minimum inhibitory concentrations, synergy, fractional inhibitory concentration index (FICI), and time kill assays were determined by broth microdilution. Electron microscopy (EM) was used to determine the qualitative changes brought about after treatment with K21. Results: K21 inhibited the growth of all fluconazole-resistant and susceptible Candida strains with only 2 h of exposure required to effectively kill 99.9% of the inoculum, and a definite synergistic effect was observed with a combination of K21 and fluconazole. EM demonstrated the presence of two forms of extracellular vesicles indicative of biofilm formation and cell lysis. Conclusion: The study established the efficacy of K21 as an antifungal agent and with fluconazole-resistant candidiasis on the increase, the development of K21 can provide a promising alternative to combat acquired drug resistance.

Topical gentian violet compared with nystatin oral suspension for the treatment of oropharyngeal candidiasis in HIV-1-infected participants

OBJECTIVE

Compare the safety and efficacy of topical gentian violet with that of nystatin oral suspension (NYS) for the treatment of oropharyngeal candidiasis in HIV-1-infected adults in resource-limited settings.

DESIGN

Multicenter, open-label, evaluator-blinded, randomized clinical trial at eight international sites, within the AIDS Clinical Trials Group.

STUDY PARTICIPANTS AND INTERVENTION

Adult HIV-infected participants with oropharyngeal candidiasis, stratified by CD4 cell counts and antiretroviral therapy status at study entry, were randomized to receive either gentian violet (0.00165%, BID) or NYS (500 000 units, QID) for 14 days.

MAIN OUTCOME MEASURE(S)

Cure or improvement after 14 days of treatment. Signs and symptoms of oropharyngeal candidiasis were evaluated in an evaluator-blinded manner.

RESULTS

The study was closed early per Data Safety Monitoring Board after enrolling 221 participants (target = 494). Among the 182 participants eligible for efficacy analysis, 63 (68.5%) in the gentian violet arm had cure or improvement of oropharyngeal candidiasis versus 61 (67.8%) in the NYS arm, resulting in a nonsizable difference of 0.007 (95% confidence interval: -0.129, 0.143). There was no sizable difference in cure rates between the two arms (-0.0007; 95% confidence interval: -0.146, 0.131). No gentian violet-related adverse events were noted. No sizable differences were identified in tolerance, adherence, quality of life, or acceptability of study drugs. In gentian violet arm, 61 and 39% of participants reported 'no' and 'mild-to-moderate' staining, respectively. Cost for medication procurement was significantly lower for gentian violet versus NYS (median $2.51 and 19.42, respectively, P = 0.01).

CONCLUSION

Efficacy of gentian violet was not statistically different than NYS, was well tolerated, and its procurement cost was substantially less than NYS.

Fresh Garlic Extract Enhances the Antimicrobial Activities of Antibiotics on Resistant Strains in Vitro

Background:

Infections caused by strains with multi-drug resistance are difficult to treat with standard antibiotics. Garlic is a powerful remedy to protect against infections of many bacteria, fungi and viruses. However, little is known about the potentials of fresh garlic extract (FGE) to improve the sensitivity of multi-drug resistant strains to antibiotics.

Objectives:

In this study, we used the disk diffusion method to investigate the antimicrobial activities of FGE and the combination of antibiotics with FGE, on methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa and Candida albicans, to evaluate the interactions between antibiotics and FGE.

Materials and Methods:

Clinical isolates were isolated from clinical specimens obtained from the inpatients at the First Affiliated Hospital of Xi’an Jiaotong University Health Science Center. The isolates consisted of MRSA, (n = 30), C. albicans (n = 30) and P. aeruginosa (n = 30). Quality control for CLSI (Clinical and Laboratory Standards Institute) disk diffusion was performed using S. aureus ATCC®25923, C. albicans ATCC®90028 and P. aeruginosa ATCC®27853. The 93 microorganisms were divided into four groups in a factorial design: control (deionized water), FGE, antibiotics without FGE, and antibiotics with FGE. Next, antibacterial activity was evaluated by measuring the diameter of inhibition zones according to performance standards for antimicrobial susceptibility testing of the Clinical and Laboratory Standards Institute (CLSI, formerly NCCLS).

Results:

Fresh garlic extract displayed evident inhibition properties against C. albicans and MRSA, yet weak inhibition properties against P. aeruginosa. Additionally, FGE showed the potential to improve the effect of antibiotics on antibiotic resistant pathogens. The synergism of fluconazole and itraconazole with FGE on C. albicans yielded larger sized inhibition zones compared with fluconazole and itraconazole without FGE (P < 0.01). The factorial analysis represents intense positive interaction effects (P < 0.01). The synergism of cefotaxime and ceftriaxone with FGE on P. aeruginosa yielded larger sized inhibition zones than cefotaxime and ceftriaxone without FGE (P < 0.01). The factorial analysis represents intense positive interaction effects (P < 0.01).

Conclusions:

The results suggest that FGE can improve the antibiotic sensitivity of these pathogens to some antibiotics.

Assessment of antifungal activity of herbal and conventional toothpastes against clinical isolates of Candida albicans

OBJECTIVE

To detect the anticandidal activity of nine toothpastes containing sodium fluoride, sodium monofluorophosphate and herbal extracts as an active ingredients against 45 oral and non oral Candida albicans (C. albicans) isolates.

METHODS

The antifungal activity of these toothpaste formulations was determined using a standard agar well diffusion method. Statistical analysis was performed using a statistical package, SPSS windows version 15, by applying mean values using one-way ANOVA with post-hoc least square differences (LSD) method. A P value of less than 0.05 was considered significant.

RESULTS

All toothpastes studied in our experiments were effective in inhibiting the growth of all C. albicans isolates. The highest anticandidal activity was obtained from toothpaste that containing both herbal extracts and sodium fluoride as active ingredients, while the lowest activity was obtained from toothpaste containing sodium monofluorophosphate as an active ingredient. Antifungal activity of Parodontax toothpaste showed a significant difference (P< 0.001) against C. albicans isolates compared to toothpastes containing sodium fluoride or herbal products.

CONCLUSIONS

In the present study, it has been demonstrated that toothpaste containing both herbal extracts and sodium fluoride as active ingredients are more effective in control of C. albicans, while toothpaste that containing monofluorophosphate as an active ingredient is less effective against C. albicans. Some herbal toothpaste formulations studied in our experiments, appear to be equally effective as the fluoride dental formulations and it can be used as an alternative to conventional formulations for individuals who have an interest in naturally-based products. Our results may provide invaluable information for dental professionals.

Virulence of oral Candida isolated from HIV-positive women with oral candidiasis and asymptomatic carriers

OBJECTIVE

This study compared the virulence of oral Candida species isolated from human immunodeficiency virus (HIV)-positive women with and without oral candidiasis.

STUDY DESIGN

Candida species were isolated from 197 women, and their virulence attributes were measured.

RESULTS

Of the 197 women, 117 (59.4%) carried Candida. Of these, 15 (12.8%) had symptoms of oral candidiasis. Among highly active antiretroviral therapy (HAART)-naive patients, 33% were diagnosed with oral candidiasis, whereas 5.9% were asymptomatic carriers (P < .01). C. albicans was the predominant species, with higher virulence attributes than non-albicans Candida. Women diagnosed with oral candidiasis had higher levels of Candida (P = .02) than asymptomatic carriers. There was no difference in the CD4 counts and the virulence attributes of Candida from both the groups.

CONCLUSIONS

This study indicates that oral candidiasis is mainly caused by high counts of C. albicans and suggests the importance of therapies targeting Candida counts in the oral cavity even in patients on HAART to reduce the development of infections.

Oral Candida colonization in HIV-positive women: associated factors and changes following antiretroviral therapy

There is a paucity of information about the factors associated with oral colonization with Candida species and the changes associated with antiretroviral (ARV) therapy. This study investigated the role of ARV therapy and other factors in a study population. Relevant clinical and laboratory information was obtained and oral rinse specimens were tested for yeast identification. The findings were compared with previous data from the same clinic before ARV therapy was available. Of 197 patients, 117 (59.4 %) were colonized. Candida albicans was the dominant species (71 %) and Candida dubliniensis was the most frequent non-albicans Candida. The colonized group had a higher rate of concurrent tuberculosis (TB) infection (77.4 % compared with 56 % in the non-colonized patients, P = 0.03) and a lower median CD4(+) count (346.5 cells mm(-3)) compared with the non-colonized group (418 cells mm(-3)). Participants not on ARV therapy and those having oral prosthesis were all colonized (P = 0.003 and P = 0.022, respectively). The oral Candida count was negatively correlated with the CD4(+) count in participants on ARV therapy (P = 0.006). Associated factors using logistic regression were dental caries (odds ratio = 1.30; 95 % confidence interval = 1.07-1.60] and diabetes mellitus (odds ratio = 5.52; 95 % confidence interval = 1.68-18.12). The colonization rate was higher (81.3 %) as well as the yeast count before ARV therapy was available, while the prevalence of C. dubliniensis was found to have increased from 6.3 to 11 %. Dental caries, diabetes mellitus, oral prostheses and TB infection were associated with oral colonization. The colonization rate, variety and yeast counts declined with ARV therapy.

Isolation, identification, and carriage of candidal species in PHLAs and their correlation with immunological status in cases with and without HAART

AIMS AND OBJECTIVES

To know the prevalence of Candidal colonization, and to isolate and know the Candidal species prevalent in the oral cavity from the oral rinse samples collected from the individuals attending to the Voluntary Counseling and Confidential Testing Center (VCCTC) and the antiretro-viral therapy (ART) Center at Government General Hospital, Guntur, Andhra Pradesh, South India.

MATERIALS AND METHODS

The study group consisted of 50 HIV negative asymptomatic individuals (Group I); 50 HIV positive individuals (people living with HIV AIDS [PLWHA's]), who are naïve to antiretro-viral therapy (direct walk-in clients of VCCTC) (Group II); and 50 HIV positive individuals with CD4+ count less than 250 and who are started on highly active anti retroviral therapy (HAART) (Group III). Routine mycological tests for the isolation of pure cultures of Candida and also the speciation procedures were done.

RESULTS

In the study group, 53 (Group I=11; Group II=23; Group III=19) were culture positive. The prevalence of Candida was comparatively high in the age range between 41-50 years in Group II; 51-60 years, in Group III. A male predominance was observed in the Group I (M:F=16:6) and Group III (M:F=20:18), with a slight female predominance in the Group II (F:M=24:22). The overall culture positivity was 35.3%. Candida albicans was the highest prevalent species (47.17% of the isolates). A comparison of the culture positivity with the CD(4) counts of the study subjects was statistically highly significant. A pair wise comparison of the culture positivity with that of the colony forming units/mL from the subjects showed a high significance between Group I and Group II, and between Group I and Group III.

CONCLUSION

Candidal infections in immuno compromised patients are often severe, rapidly progressive, and difficult to treat and such patients have a definitive risk of developing oral candidiasis wherein, even the members of the normal oral flora may become pathogenic. Candida albicans is the common isolate. Nonalbicans species are also emerging as opportunistic pathogens. In view of this changing pattern, it is strongly recommended that species identification can help in much better treatment strategies, and thus, gain a good control over the disease. The findings of this study would be helpful in any further studies which, if done prospectively on a larger cohort, can be confirmatory.

Oropharyngeal yeast colonization in HIV-infected outpatients in southern Taiwan: CD4 count, efavirenz therapy and intravenous drug use matter

To understand the status of oropharyngeal yeast colonization in human immunodeficiency virus (HIV) -infected outpatients in the era of highly active antiretroviral therapy (HAART), we conducted a prospective, cross-sectional study from October 2009 to January 2010 at a medical centre in southern Taiwan. Fungal cultures of the oropharyngeal swabs were performed on 327 enrolled patients. At enrolment, 258 (79%) patients had been receiving HAART, and 42 (12.8%), 73 (22.3%) and 212 (64.8%) patients had CD4 cell counts ≤200, 201-350, and >350 cells/mm(3) , respectively. Oral yeast colonization was detected in 193 (59%) patients, among whom 157 (81.3%), 25 (13.0%), and 11 (5.7%) were colonized by a single, two and more than two species, respectively. Multivariate analysis showed that receipt of efavirenz-containing regiments and CD4 cell counts >200 cells/mm(3) were associated with lower risks of oral yeast colonization, while intravenous drug users were at a higher risk. Among the 241 isolates recovered, Candida albicans accounted for 69.7%, followed by C. dubliniensis (9.5%), C. glabrata (8.3%), C. tropicalis (3.3%), C. intermedia (2.1%), C. parapsilosis (1.7%), and 11 other species (5.4%). Overall, 230 (95.4%), 236 (97.9%) and 240 (99.6%) isolates were susceptible to fluconazole, voriconazole and amphotericin B, respectively. In conclusion, colonization by C. dubliniensis has emerged in recent years. In addition to a CD4 cell count ≤200 cells/mm(3) , which is a known risk factor for oropharyngeal yeast colonization in HIV-infected patients that was identified in our previous studies, two risk factors, non-receipt of efavirenz-based combinations and intravenous drug use, were first identified in the present study. Fluconazole remained effective in vitro against the yeasts colonizing the oropharynx in this population.

Candida pelliculosa meningitis as an opportunistic infection in HIV: the first reported case

We describe the first reported case of Candida pelliculosa meningitis in HIV infection. This case highlights the risk of uncommon opportunistic infections in association with the immunocompromised and the importance of autopsy as a diagnostic tool in HIV infection. We discuss the epidemiology, diagnosis and management of C. pelliculosa, a non-albicans species which is rarely associated with disease, and review current literature.

Conventional and alternative antifungal therapies to oral candidiasis

Candida-associated denture stomatitis is the most common form of oral candidal infection, with Candida albicans being the principal etiological agent. Candida adheres directly or via an intermediary layer of plaque-forming bacteria to denture acrylic. Despite antifungal therapy to treat denture stomatitis, infection is reestablished soon after the treatment ceases. In addition, many predisposing factors have been identified as important in the development of oral candidiasis, including malnourishment, common endocrine disorders, such as diabetis mellitus, antibacterial drug therapy, corticosteroids, radiotherapy and other immunocompromised conditions, such as acquired immunodeficiency syndrome (AIDS). These often results in increased tolerance to the most commonly used antifungals. So this review suggests new therapies to oral candidiasis.

Antifungal effect of mouth rinses on oral Candida counts and salivary flow in treatment-naïve HIV-infected patients

Oral candidiasis is a major problem in developing countries where antiretroviral therapy is available to a small percentage of the infected population. HIV patients are prone to xerostomia and predisposed to Candida infection. Preventing oral candidiasis is better than the frequent use of antifungals that may lead to the development of drug resistance. This study investigated the ability of commercial mouth rinses and sodium bicarbonate to reduce salivary Candida and to improve the saliva flow of HIV-positive patients. One hundred fifty HIV patients without oral candidiasis were examined for oral lesions initially and after 2, 4, and 12 weeks. Unstimulated saliva was collected; the volume was measured and cultured for yeasts. Subjects were provided with mouth rinses containing either benzydamine hydrochloride, benzydamine hydrochloride with chlorhexidine gluconate, triclosan with sodium fluoride, 5% sodium bicarbonate, or placebo and asked to rinse twice daily for 12 weeks. The effect of the mouth rinses and placebo on Candida counts and saliva flow was analyzed using analysis of variance (ANOVA). A total of 108 patients completed the trial, 35 missed appointments, 4 died, 2 developed oral candidiasis, and 1 herpetic lesion. Triclosan/fluoride decreased the Candida count more than the placebo (p = 0.005) while chlorhexidine/benzydamine hydrochloride (p = 0.001) and triclosan/fluoride mouthrinses (p = 0.002) increased the salivary flow during the initial 4 weeks. The most effective mouth rinse triclosan/fluoride decreased oral Candida counts and increased saliva flow. Studies are needed to determine the efficacy of these mouth rinses for the long-term prevention of clinical oral candidiasis in adult HIV-positive patients.