Esophageal infections usually occur in the setting of profound immunosuppression. If it is possible to safely discontinue any medications contributing to immunosuppression (e.g., corticosteroids) or to reverse the underlying condition causing the immunocompromise (e.g., by administering highly active antiretroviral therapy to patients with AIDS), doing so will likely improve the outcome of treatment for infectious esophagitis.

Treatment of candida esophagitis. Although topical therapies (e.g., clotrimazole troches, nystatin swish and swallow) are used to treat oropharyngeal candidiasis in patients without AIDS, candida esophagitis generally is thought to require treatment with a systemic antifungal agent. Treatment can include azoles (fluconazole, itraconazole, voriconazole, posaconazole), echinocandins (caspofungin, micafungin, anidulafungin) or, uncommonly, amphotericin B.

Treatment of HSV esophagitis. For immunocompetent patients with HSV esophagitis, spontaneous resolution generally can be expected within 2 weeks, and no treatment may be necessary. Although there is no published therapeutic trial to guide treatment for immunocompetent patients with HSV esophagitis, it has been suggested that a short course of acyclovir may hasten the resolution of symptoms. Treatment is virtually always recommended for immunocompromised patients.

Treatment of CMV esophagitis. CMV infections often occur within 4 months of organ transplantation if patients are not given prophylaxis, and within 4 months of discontinuing prophylaxis. The clinician should consider decreasing or stopping some immunotherapeutic agents in this setting, and the risks of continuing immunotherapy in the presence of CMV infection must be balanced against the risk of transplant rejection if immunotherapy is stopped. Agents available for the treatment of CMV infection include ganciclovir, valganciclovir, foscarnet, and cidofovir.