Efficacy of melaleuca oral solution for the treatment of

fluconazole refractory oral candidiasis in AIDS patients

Alena Jandourek, Julie K. Vaishampayan and Jose A. Vazquez

Objective: To evaluate the efficacy of melaleuca oral solution in AIDS patients with
fluconazole-resistant oropharyngeal candida infections.
Design: A prospective, single center, open-labeled study.
Setting: A university-based inner-city HIV/AIDS clinic.
Patients: Thirteen patients with AIDS and oral candidiasis documented to be
clinically refractory to fluconazole, as defined by failure to respond to a minimum of
14 days of 400 mg fluconazole per day. Additionally, patients had in vitro
resistance to fluconazole, defined by minimal inhibitory concentrations of 20
g/ml.
Interventions: Patients were given 15 ml melaleuca oral solution four times daily to
swish and expel for 24 weeks.
Main outcome measures: Resolution of clinical lesions of oral pseudomembranous
candidiasis lesions. Evaluations were performed weekly for 4 weeks and at the end
of therapy for clinical signs of oral candidiasis. Quantitative yeast cultures were
performed at each evaluation.
Results: A total of 13 patients were entered into the study, 12 were evaluable. At
the 2-week evaluation, seven out of 12 patients had improved, none were cured,
and six were unchanged. At the 4-week evaluation, eight out of 12 patients showed
a response (two cured, six improved), four were non-responders, and one had
deteriorated. A mycological response was seen in seven out of 12 patients. A follow-
up evaluation 24 weeks after therapy was discontinued revealed that there were no
clinical relapses in the two patients who were cured.
Conclusions: Melaleuca oral solution appears to be effective as an alternative
regimen for AIDS patients with oropharyngeal candidiasis refractory to fluconazole.
1998 Lippincott-Raven Publishers

AIDS 1998, 12:10331037

Keywords: Fluconazole refractory, mucosal candidiasis, melaleuca oral solution

Introduction oral candida infection including nystatin, amphotericin

Oropharyngeal candidiasis (OPC) is the most common
opportunistic infection observed in patients with
HIV/AIDS [1,2]. Approximately 8090% of patients
with AIDS will develop OPC at some stage [3,4].
Candida albicans accounts for the overwhelming major-
ity of cases of oral thrush [4], which impairs the quality
of life and may result in a reduction in fluid or food
intake. There are several antifungals available to treat
B, clotrimazole, miconazole, itraconazole, fluconazole,
and ketoconazole. Several of these are systemic and
there is always a potential for drug interactions. The
incidence of fluconazole-refractory OPC is becoming
increasingly more common and frequently may emerge
during therapy [5,6]. Intravenous amphotericin B has
been effective therapy for refractory OPC, but this
approach is inconvenient, expensive and associated
with significant morbidity.

From the Department of Medicine, Division of Infectious Diseases, Wayne State University School of Medicine, Detroit,
Michigan, USA.
Note: This work was presented in part at the XI International Conference on AIDS, Vancouver, July 1996.
Requests for reprints to: Dr Jose A. Vazquez, Associate Professor of Medicine, Division of Infectious Diseases, Wayne State
University School of Medicine, 4160 John R, Suite 2140, Detroit, MI 48201, USA.
Date of receipt: 19 September 1997; revised: 12 February 1998; accepted: 18 February 1998.

Lippincott-Raven Publishers 1033

1034 AIDS 1998, Vol 12 No 9
Melaleuca oral solution (Breath-Away, Melaleuca, Inc.,
Idaho Falls, Idaho, USA) is a non-prescription mouth-
wash preparation with documented in vitro activity
against yeast and fungi, which is derived from Melaleuca
alternafolia, an Australian tea leaf [7,8]. This small single
center prospective study assessed the efficacy and safety
of melaleuca oral solution in AIDS patients with
fluconazole-refractory OPC.
Patient and methods
Patients
Men and women between the ages of 18 and 65 years
were eligible for study entry if they were HIV-positive
and met the criteria for the diagnosis of OPC of either
the pseudomembranous or erythematous (atrophic)
variety. The two entry criteria were as follows: (i) the
presence of OPC characterized by creamy, white,
curd-like patches, removable by scraping, or typical
erythematous lesions on the oral mucosal surfaces, and
a KOH test consistent with Candida spp. and subse-
quently confirmed by fungal culture; and (ii) all patients
must have failed to respond to a minimum of 14 days
of 400 mg daily fluconazole within 14 days of study
entry.
Study design
A single center, open-label clinical trial was conducted
to evaluate melaleuca oral solution four times daily for
the treatment of fluconazole-refractory OPC in 13
AIDS patients. Patients were treated with a 15 ml
mouth swish and expel (see below) of melaleuca oral
solution four times daily for 2 weeks, and an additional
2 weeks for patients who showed clinical improvement
but who had not demonstrated a complete clinical
response at the end of the initial 2 weeks of therapy.
The clinical study protocol was approved by the
Institutional Review Board at our institution and each
patient provided written informed consent prior to
study participation.
Drug dosing and administration
Melaleuca oral solution was provided in 118 ml bottles.
Patients were instructed to take 15 ml of the solution
four times daily for 14 days. The solution was to be
swished in the mouth for 3060 sec and then expelled,
with no rinsing afterwards for at least 30 min.
Efficacy and evaluations
On enrollment at the first visit, a complete and history
and physical examination was performed. Evaluation of
signs and symptoms was carried out and recorded. The
severity of soreness, burning and erythema were scored
on a 03 scale as follows: absent, 0; mild, 1; moderate,
2; severe, 3. The extent of the lesions were scored as
follows: absent, 0; single, localized, 1; multiple, local-
ized, 2; extensive or confluent, 3. All affected sites were
recorded diagrammatically. The severity score was the
total score of soreness and burning plus erythema plus
the extent of the lesions.
Clinical evaluations were also performed on days 7 and
14, and also on days 28 and 42 of follow-up.
Assessments of signs and symptoms of OPC were con-
ducted by an evaluator (J.A.V.), and grading was per-
formed. OPC was considered to be cured when
clearance of all signs and symptoms occurred,
improved when minimal signs and symptoms with
minimal residual visible lesions of OPC were observed,
unchanged when there was no change in signs and
symptoms or the need for continued treatment, and
deteriorated when there was worsening or increasing
signs and symptoms. At end of therapy an assessment of
cured or improved was considered a clinical
response.
Mycological evaluation
Mycological assessments included a KOH test, fungal
culture on Sabouraud dextrose agar, yeast quantifica-
tion, and in vitro susceptibility studies. Yeast quantifica-
tion was performed using c.f.u./ml of Candida spp.
recovered. The test was performed using a 15 sec
mouthwash procedure with 15 ml normal saline, which
was swished in the mouth and expelled into a
50 ml tube. Afterwards, 100 l of the suspension was
plated on Sabouraud dextrose plates and colonies
counted. The mouthwash procedure was performed
before breakfast and before taking any test medication
the day of the follow-up. Mycological cure was defined
as below 20 c.f.u./ml on mouthwash quantification
studies. Negative culture was defined as no growth on
culture plate. Yeast isolates were identified using germ
tube formation, chlamydospore formation on cornmeal
agar, and the API 20C method (Biomerieux, Vitek,
Inc., Hazelwood, Missouri, USA).
In vitro susceptibility studies were performed using flu-
conazole, ketoconazole, itraconazole and amphotericin
B for each initial isolate from all patients enrolled into
the study. The minimal inhibitory concentrations
(MIC) of all antifungal agents for all isolates were
determined in accordance with the National
Committee for Clinical Laboratory Standards M27-P
protocol by a broth microdilution method for all anti-
fungals [9]. A standard inoculum was diluted to a final
concentration of 0.52.5 103 c.f.u./well in microtiter
plates containing RPMI-1640 medium. The final
concentrations of fluconazole were 0.1680 g/ml,
those of itraconazole and ketoconazole were 0.0512.5
g/ml, and those of amphotericin B were 0.0063.1
g/ml. An overall response was defined as a clinical
response plus a mycological response.
Assessments for adverse events were performed during
visits, at the end of therapy, and at follow-up. Physical
 Melaleuca for fluconazole-resistant thrush in AIDS Jandourek et al. 1035

examination was performed at the end of the treatment Table 2. Clinical and mycological outcomes at 2- and 4-week eval-
period. Clinical laboratory tests, hematology, blood uations.
chemistry and urinalysis were performed at baseline and Week 2 Week 4
during treatment as clinically indicated. Outcome (n = 12) (n = 12)
Cured 0 2
Improved 7 6
Unchanged 6 4
Deteriorated 0 1
Results Clinical response (cured or improved) 7 8
Mycological response 5 7
Overall response (mycological plus
Thirteen patients were enrolled in the study. One clinical response) 5 7
patient was enrolled but never returned for follow-up
(patient 11). The 12 evaluable patients had a mean age
of 33 years (range, 2848 years), and all 12 were men, six were still unchanged (Table 2). At the end of the
with a median CD4 cell count of 10 106/l; seven study period (6 weeks), both of the patients who were
were black, five were Caucasian, and one was cured remained relapse-free for at least 2 weeks after
Hispanic. All patients had a history of at least one prior the last study dose.
episode of OPC. In addition, 10 out of 13 patients had
at least one AIDS-defining illness prior to fluconazole- Mycological assessments
refractory thrush. The most common events were All 13 patients who provided informed consent and
Pneumocystis carinii pneumonia (six patients), Candida were entered into the study had positive oral cultures
esophagitis (five patients), Mycobacterium tuberculosis for yeast on study entry. C. albicans was the only yeast
infection (three patients), cytomegalovirus retinitis (one recovered from the oral specimens. Table 1 shows the
patient), and Kaposis sarcoma (one patient). Baseline fungal colony counts at baseline and at the 4-week
evaluations of patients are shown in Table 1. follow-up. Nine out of 12 patients had significant
decreases in colony counts after 4 weeks of therapy
Clinical outcomes with melaleuca.
The evaluation of clinical efficacy was based on an
intention-to-treat analysis (Table 2). Clinical response In vitro susceptibilities of the C. albicans isolates revealed
to the melaleuca solution was observed in eight that all isolates had an MIC to fluconazole of
patients. Two patients were clinically cured and six > 20 g/ml (range, 2080 g/ml), a 50% MIC (MIC50)
were improved after 28 days of therapy. Four patients of 40 g/ml, and a 90% MIC (MIC 90) of 80 g/ml.
were unchanged after 28 days of therapy and one The MIC 5 0 of amphotericin B was 0.05 g/ml
patient deteriorated by developing esophageal candidia- (0.020.4 g/ml). Itraconazole had an MIC 50 of
sis. Thus, 16.7% of the patients were clinically cured 0.4 g/ml (range, 0.0212.5 g/ml), and ketoconazole
and an additional 50% were clinically improved for an had an MIC50 of 0.01 g/ml (range, 0.010.05 g/ml).
overall clinical response rate of 67% (eight out of 12). It
is important to note that although the response rate at Adverse events
the end of 4 weeks was 67%, at the end of the initial There were no serious adverse events. Evaluation for
2-week follow-up period no patients were cured and adverse events revealed that eight of the 12 patients
Table 1. Clinical severity score and mycology results.
Severity scores c.f.u./ml
Patient Baseline Week 1 Week 2 Week 4 Baseline Week 4
1* 1, 2, 3 0, 1, 3 0, 1, 3 0, 0, 2 TNTC TNTC
2 1, 2, 3 0, 1, 2 NS 0, 1, 2 TNTC < 50
3 1, 1, 3 1, 1, 3 1, 1, 3 1, 1, 3 TNTC TNTC
4 3, 2, 3 1, 1, 2 0, 0, 1 0, 0, 0 TNTC < 50
5 1, 1, 3 0, 1, 3 1, 1, 3 NS TNTC 20
(36 weeks 0, 0, 0)
6 2, 2, 2 NS 0, 1, 2 0, 0, 0 TNTC < 50
7 1, 2, 2 0, 2, 2 NS 0, 0, 0 TNTC < 10
8 0, 2, 2 0, 1, 2 0, 1, 2 0, 0, 2 TNTC 300
9 2, 2, 2 0, 0, 2 NS 0, 0, 1 TNTC 180
(34 weeks 0, 0, 0)
10* 1, 2, 3 NS 0, 0, 2 0, 0, 2 TNTC 100
11* 1, 2, 3 NS NS NS TNTC ND
12* 2, 3, 3 NS NS 0, 2, 2 TNTC 140
13 2, 2, 3 0, 1, 3 NS 0, 0, 0 TNTC ND
*Patients non-adherent to regimen. First number indicates severity/burning: absent, 0; mild, 1; moderate, 2; severe, 3; second number indi-
cates erythema: absent, 0; mild, 1; moderate, 2; severe, 3; third number indicates extent: absent, 0; single, localized, 1; multiple, localized,
2; extensive or confluent, 3. NS, Not seen; ND, not determined; TNTC, too numerous to count.
1036 AIDS 1998, Vol 12 No 9
noted mild-to-moderate oral burning when the solu-
tion came into contact with their oral mucosa. This
complaint was primarily noted the first week of therapy
and gradually decreased with improvement of OPC.
No new laboratory abnormalities developed during the
study period. However, a significant problem was
noted with compliance. Four of the patients enrolled
were non-adherent with the study regimen prescribed
or did not attend their scheduled clinic visits.
Discussion
There is a growing interest in the use of naturally
occurring substances for the treatment of a variety of
medical conditions. Melaleuca (tea tree oil) has been
used as a natural topical antiseptic since the early part of
this century [8,10]. It has also been used as an antiseptic
agent in denture and mouth washes. Melaleuca oil has
been previously analyzed by gas chromatography and a
large number of its chemical constituents have been
defined [11]. In addition, melaleuca has been tested for
its antibacterial and antifungal activity in vitro.
Staphylococcus aureus and most of the Gram-negative
bacteria tested were found to be susceptible using a
modified broth microdilution method [10,12]. The
antimicrobial activity of eight of the components of tea
tree oil were also evaluated using disc diffusion and
broth microdilution methods against C. albicans,
Escherichia coli and S. aureus [13]. These organisms were
all found to be susceptible to melaleuca in these in vitro
studies. In addition, Nenoff et al. [14] have recently
completed a study investigating the in vitro activity of
M. alternifolia oil against 26 strains of dermatophytes and
54 strains of yeast. Their results demonstrate that the
melaleuca oil preparation used effectively inhibited
growth of all clinical fungal isolates at concentrations of
0.50.44%. These concentrations are far lower than the
510% concentrations from many of the clinically
available melaleuca preparations.
More recently, tea tree oil has been used in treatment
trials for tinea pedis. A comparative study of topical
clotrimazole versus M. alternifolia oil for the treatment
of onychomycosis was recently published. The study
was a double-blind, multicenter, randomized trial that
enrolled 117 patients with distal subungual onychomy-
cosis and followed them for 6 months for signs and
symptoms of improvement. Improvement was noted in
55% of patients on clotrimazole and in 56% of patients
on melaleuca [15]. A second study published in 1992,
however, gave conflicting results. In this study, use of
tea tree oil was compared with 1% tolnaftate ointment
or placebo creams in patients with tinea pedis. In this
study, 85% of the patients on the tolnaftate arm had
negative fungal cultures at the end of study, whereas
30% of the tea tree oil-treated patients, and 21% of the
placebo-treated patients, had negative cultures [16].
To our knowledge, our study is the first to evaluate the
treatment of fluconazole-refractory OPC in patients
with advanced AIDS using melaleuca oral solution.
The clinical outcome in this study population demon-
strated a greater than 65% efficacy in this advanced,
immunocompromised patient population. Only one
patient deteriorated while on therapy when he devel-
oped esophageal candidiasis. However, this event has
previously been reported with other forms of topical
antifungal therapy such as nystatin, amphotericin B or
clotrimazole, and is difficult to predict. Many patients
with HIV infection are treated with topical antifungals
for OPC. Similarly, treatment with topical antifungal
agent therapy such as melaleuca is not intended to treat
esophageal candidiasis, but to alleviate oral symptoms
and improve the well-being of patients with flucona-
zole-refractory OPC.
We feel that the results of this pilot study are extremely
promising and that further large, comparative multicen-
ter studies using melaleuca oral solution are warranted.
Moreover, M. alternafolia may become an alternative
antifungal agent for the treatment of OPC in either the
early or late stages of HIV infection.
Acknowledgements
The authors thank Melaleuca, Inc. (Idaho Falls, Idaho,
USA) for providing the Breath-Away oral solution
used in this study and Eileen Surma for the excellent
secretarial support.
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