***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Progressive cell-mediated immunodeficiency with decrease of CD4 + lymphocyte count to less than or equal to 200 cells/mm3 is a major risk factor for colonization with C and ida species and development of c and idiasis . Oropharyngeal c and idiasis may occur in up to 90 % of human immunodeficiency virus (HIV)-infected patients during the course of the disease . This study is to determine the effect of prolonged highly active antiretroviral therapy ( HAART ) on oropharyngeal colonization with C and ida species and oral c and idiasis . Methods A prospect i ve , longitudinal follow-up study in HIV-infected patients receiving HAART .  Results The mean CD4 + count increased from 232.5 to 316 cells/mm3 and the proportion of patients whose CD4 + count less than 200 cells/mm3 decreased from 50.0 % to 28.9 % ( p = 0.0003 ) in patients receiving HAART for at least 2 years . The prevalence of oral c and idiasis decreased from 10.6 % to 2.1 % ( p = 0.004 ) . The decrease in C and ida colonization was less impressive , falling from 57.8 % to 46.5 % ( p = 0.06 ) . Of the 142 patients enrolled in at least two surveys , 48 ( 33.8 % ) remained colonized with C and ida and 42 ( 29.6 % ) remained negative . In the remaining 52 patients , 34 switched from culture positive to negative , and an increase in CD4 + lymphocytes was noted in 91.2 % of them . Among the 18 patients who switched from culture negative to positive , 61.1 % also demonstrated an increase in CD4 + lymphocyte count ( p = 0.01 ) . Conclusion These findings indicate that HAART is highly effective in decreasing oral c and idiasis in association with a rise in CD4 + lymphocyte counts , but only marginally effective in eliminating C and ida from the oropharynx Objective : To evaluate the efficacy of itraconazole cyclodextrin solution in fluconazole-refractory oropharyngeal c and idiasis ( OPC ) , and to correlate clinical outcome with in vitro susceptibility and serum azole levels . Design : A prospect i ve , open-label , intervention study . Setting : A university hospital , which serves as the provincial HIV referral center . Patients and interventions : Thirty-six HIV-infected individuals referred for fluconazole-refractory OPC were evaluated prospect ively between May 1993 and March 1995 , including clinical assessment , serum azole levels , and susceptibility testing of C and ida spp . isolates . Itraconazole solution was administered orally at a daily dose of 200 mg for 14 days , followed by suppressive therapy .  Thirty-four patients were evaluable . Main outcome measure : Resolution of oral pseudomembranous lesions . Results : Initial isolates were C and ida albicans ( n = 33 ) , C. glabrata ( n = 1 ) , C. krusei ( n = 1 ) , and mixed infection with C. albicans and C. krusei ( n = 1 ) .  Fluconazole serum levels obtained at the time of failed therapy ranged from 4.7 to 40 mg/l ( median , 12.9 mg/l ) . Itraconazole was generally well tolerated . Clinical responses were observed in 65 % ( 22 out of 34 ) of evaluable cases . Among the responders , relapse had occurred within 2 months for four ( 36 % ) out of 11 cases who continued with follow-up . The median fluconazole minimal inhibitory concentration ( MIC ) was 64 mg/l for isolates from fluconazole-refractory cases , compared with a median of 0.5 mg/l for control isolates ( P = 0.002 ) . The median itraconazole MIC for isolates from fluconazole-refractory cases was 1.25 mg/l , compared with a median of 0.078 mg/l for controls ( P = 0.011 ) . Conclusion : A correlation between clinical response and in vitro susceptibility was clearly demonstrated for fluconazole , but not for itraconazole . Itraconazole cyclodextrin solution may be effective for fluconazole-refractory OPC and should be considered prior to salvage therapy with intravenous amphotericin OBJECTIVES --To compare the tolerance , efficacy , and pharmacokinetics of amphotericin deoxycholate ( Fungizone ) prepared in a parenteral fat emulsion ( Intralipid 20 % ) or glucose in HIV patients with c and idiasis . DESIGN --Non-blind r and omised controlled trial . SETTING --University hospital ; tertiary clinical care . PATIENTS --22 HIV positive patients with oral c and idiasis . INTERVENTIONS --Amphotericin 1 mg/kg/day given on four consecutive days as a one hour infusion dissolved in either 5 % glucose ( amphotericin-glucose ) or parenteral fat emulsion at a final concentration of 2 g/l fat emulsion ( amphotericin-fat emulsion ) . MAIN OUTCOME MEASURES -- Clinical tolerance ( fever , chills , sweats , nausea , arterial pressure , and pulse rate ) ; biological tolerance ( serum creatinine , electrolyte , and magnesium values ) ; clinical score of c and idiasis ; and serum concentrations of amphotericin .  RESULTS --11 patients were enrolled in each group . All the amphotericin-fat emulsion infusions were given without serious problem whereas four amphotericin-glucose infusions were stopped because of renal impairment ( n = 3 ) or severe chills ( n = 2 ) , or both . For patients completing the amphotericin-glucose treatment creatine concentration increased by 42 mumol/l ; four of seven patients had at least one creatinine value > or = 133 mumol/l versus one of 11 receiving amphotericin-fat emulsion .  Magnesium concentration fell significantly with amphotericin-glucose but not with amphotericin-fat emulsion .  Clinical side effects were noted in 36/38 infusions with amphotericin-glucose but 10/44 with amphotericin-fat emulsion .  Oral c and idiasis score was reduced similarly in both groups . Serum amphotericin concentrations were significantly lower and the volume of distribution of the drug higher after infusion of amphotericin-fat emulsion than after amphotericin-glucose . CONCLUSIONS -- Clinical and renal toxicity of amphotericin are reduced when the drug is prepared in fat emulsion . Preparation is simple and cost effective . Its efficacy is similar to that of conventional amphotericin In an open multicentre study the efficacy and safety of fluconazole versus ketoconazole were evaluated in the treatment of 46 pediatric patients with oropharyngeal c and idiasis and AIDS or HIV infection . Twenty-four subjects received  oral fluconazole in a dosage of 3 mg/kg/day and 22 subjects received oral ketoconazole  in a dosage of 7 mg/kg/day . The treatment duration ranged from 5 to 49 days . Results showed that fluconazole and ketoconazole have comparable efficacy and safety in the treatment of oropharyngeal c and idiasis in HIV-infected children . Patients treated with fluconazole had higher clinical and mycological cure rates at the end of therapy ( 88 % and 71 % respectively ) than those treated with ketoconazole ( 81 % and 57 % respectively ) . One case of drug-related side effects ( diarrhea and abdominal pain ) in a patient receiving ketoconazole result ed in discontinuation of treatment . Follow-up examinations 2 and 4 weeks post-treatment showed a comparably high rate of relapse in both patient groups BACKGROUND We evaluated the efficacy and safety of oral posaconazole for human immunodeficiency virus (HIV)-infected subjects with oropharyngeal c and idiasis ( OPC ) and /or esophageal c and idiasis ( EC ) who were clinical ly refractory to treatment with oral fluconazole or itraconazole . METHODS Subjects with confirmed OPC or EC who did not improve after receiving st and ard courses of fluconazole or itraconazole treatment were eligible for study enrollment . Subjects received either oral posaconazole ( 400 mg twice daily ) for 3 days followed by oral posaconazole ( 400 mg once daily ) for 25 days ( regimen A ; 103 patients ) or oral posaconazole ( 400 mg twice daily ) for 28 days ( regimen B ; 96 patients ) . The primary end point was cure or improvement after 28 days . Primary efficacy analyses were performed on the subset of treated subjects with refractory disease ( e.g. , baseline culture positive for fluconazole- or itraconazole-resistant C and ida species or persistent or progressive clinical signs or symptoms consistent with treatment failure ) . RESULTS Of the modified intent-to-treat population , 132 ( 75 % ) of 176 subjects achieved a clinical response to posaconazole treatment . Clinical response rates were similar between regimen A recipients ( 75.3 % ) and regimen B recipients ( 74.7 % ) . Clinical responses occurred in 67 ( 73 % ) of 92 subjects with baseline isolates resistant to fluconazole , 49 ( 74 % ) of 66 subjects with baseline isolates resistant to itraconazole , and 42 ( 74 % ) of 57 subjects with isolates resistant to both . Clinical response was achieved in 32 ( 74.4 % ) of 43 subjects with endoscopically documented EC . The most common treatment-related adverse events were diarrhea ( 11 % ) , neutropenia ( 7 % ) , flatulence ( 6 % ) , and nausea ( 6 % ) . Eight subjects ( 4 % ) discontinued therapy as a result of a treatment-related adverse event . CONCLUSIONS Posaconazole offers a safe and effective treatment option for HIV-infected subjects with azole-refractory OPC and /or EC CONTEXT Multiple options are now available for prophylaxis of opportunistic infections related to the acquired immunodeficiency syndrome ( AIDS ) . However , because of differences in incidence rates as well as drug efficacy , toxicity , and costs , the role of different types of prophylaxis remains uncertain . OBJECTIVE To determine the clinical impact , cost , and cost-effectiveness of strategies for preventing opportunistic infections in patients with advanced human immunodeficiency virus ( HIV ) disease . DESIGN We developed a Markov simulation model to compare different strategies for prophylaxis of Pneumocystis carinii pneumonia ( PCP ) , toxoplasmosis , Mycobacterium avium complex ( MAC ) infection , fungal infections , and cytomegalovirus ( CMV ) disease in HIV-infected patients . Data for the model were derived from the Multicenter AIDS Cohort Study , r and omized controlled trials , and the national AIDS Cost and Services Utilization Survey . MAIN OUTCOME MEASURES Projected life expectancy , quality -adjusted life expectancy , total lifetime direct medical costs , and cost-effectiveness in dollars per quality -adjusted life-year ( QALY ) saved . RESULTS For patients with CD4 cell counts of 0.200 to 0.300 x 10(9)/L ( 200 - 300/microL ) who receive no prophylaxis , we projected a quality -adjusted life expectancy of 39.08 months and average total lifetime costs of $ 40288 . Prophylaxis for PCP and toxoplasmosis with trimethoprim-sulfamethoxazole for patients with CD4 cell counts of 0.200 x 10(9)/L ( 200/microL ) or less increased quality -adjusted life expectancy to 42.56 months , implying an incremental cost of $ 16000 per QALY saved . Prophylaxis for MAC for patients with CD4 cell counts of 0.050 x 10(9)/L ( 50/microL ) or less produced smaller gains in quality -adjusted life expectancy ; incremental cost-effectiveness ratios were $ 35000 per QALY saved for azithromycin and $ 74000 per QALY saved for rifabutin . Oral ganciclovir for the prevention of CMV infection was the least cost-effective prophylaxis ( $ 314000 per QALY saved ) . Results were most sensitive to the risk of developing an opportunistic infection , the impact of opportunistic infection history on long-term survival , and the cost of prophylaxis . CONCLUSIONS The cost-effectiveness of prophylaxis against HIV-related opportunistic infections varies widely , but prophylaxis against PCP or toxoplasmosis and against MAC delivers the greatest comparative value . In an era of limited re sources , these results can be used to set priorities and explore new alternatives for improving HIV patient care Over 37 months , we conducted a prospect i ve double-blind , r and omized study in a cohort of 138 HIV-infected patients to 
    Output:
    
Implication s for practice Due to only one study in children it is not possible to make recommendations for treatment or prevention of OC in children .
Due to insufficient evidence no conclusion could be made about the effectiveness of clotrimazole , nystatin , amphotericin B , itraconazole or ketoconazole  with regard to OC prophylaxis .
In comparison to placebo , fluconazole is an effective preventative intervention .
However , the potential for resistant C and ida organisms to develop , as well as the cost of prophylaxis , might impact the feasibility of implementation .
Direction of findings suggests that ketoconazole , fluconazole , itraconazole  and clotrimazole improved the treatment outcomes .
There is also a strong need for more research to be done on the treatment and prevention of OC  in children as it is reported that OC is the most frequent fungal infection in children and adolescents who are HIV positive .