What is the treatment for recurrent oral candidiasis (thrush)?

Treatment of Recurrent Oral Candidiasis (Thrush)

For recurrent oral candidiasis, fluconazole 100 mg three times weekly is strongly recommended as chronic suppressive therapy when required for patients with frequent recurrences. 1

Initial Treatment Based on Disease Severity

Mild Disease

• First-line options:

  • Clotrimazole troches: 10 mg 5 times daily for 7-14 days 1, 2
  • Miconazole mucoadhesive buccal tablet: 50 mg applied once daily to the mucosal surface over the canine fossa for 7-14 days 1, 2

• Alternative options for mild disease:

  • Nystatin suspension: 100,000 U/mL, 4-6 mL 4 times daily for 7-14 days 1, 2
  • Nystatin pastilles: 1-2 pastilles (200,000 U each) 4 times daily for 7-14 days 1, 2

Moderate to Severe Disease

• Oral fluconazole: 100-200 mg daily for 7-14 days 1, 2
  • For severe cases, doses up to 400 mg daily may be used 2
  • Loading dose: Consider 200 mg on first day, followed by 100 mg daily 3

Management of Fluconazole-Refractory Disease

If initial treatment with fluconazole fails:

1. First alternatives:

   • Itraconazole solution: 200 mg once daily for up to 28 days 1, 4
   • Posaconazole suspension: 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 1

2. Second alternatives:

   • Voriconazole: 200 mg twice daily 1
   • Amphotericin B deoxycholate oral suspension: 100 mg/mL 4 times daily 1

3. For severe refractory disease:

   • Intravenous echinocandin (options include):
     • Caspofungin: 70-mg loading dose, then 50 mg daily 1
     • Micafungin: 100 mg daily 1
     • Anidulafungin: 200-mg loading dose, then 100 mg daily 1
   • Intravenous amphotericin B deoxycholate: 0.3 mg/kg daily 1

Management of Recurrent Oral Candidiasis

For patients with recurrent infections requiring chronic suppressive therapy:

• Fluconazole: 100 mg three times weekly 1, 2
  • This regimen has been shown to effectively prevent recurrences with minimal side effects 5

Special Considerations

HIV-Infected Patients

• Antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections 1, 2
• Recurrent thrush in HIV patients may indicate immune dysfunction, particularly with CD4 counts <200 cells/μL 1

Denture-Related Candidiasis

• Disinfection of the denture in addition to antifungal therapy is essential 1, 2
• Recommendations for denture care:
  • Remove dentures at night
  • Clean thoroughly with appropriate denture cleaners
  • Consider denture replacement if ill-fitting 2

Common Pitfalls and Caveats

1. Failure to identify and address underlying risk factors:

   • Immunosuppression
   • Diabetes mellitus
   • Broad-spectrum antibiotic use
   • Corticosteroid use (including inhaled steroids)
   • Poor oral hygiene

2. Inadequate treatment duration:

   • Premature discontinuation of therapy before complete resolution can lead to recurrence

3. Failure to recognize fluconazole resistance:

   • Particularly in patients with advanced immunosuppression or previous repeated azole exposure 1
   • Resistance may develop through acquisition of a new resistant strain or by development of resistance in a previously susceptible strain 6

4. Neglecting denture hygiene:

   • Failure to address colonized dentures will lead to treatment failure 1, 2

5. Ignoring the possibility of progression to systemic infection:

   • In severely immunocompromised patients, oral thrush can potentially lead to candidemia, especially with resistant strains 7

Remember that single-dose fluconazole (150 mg), while effective for vaginal candidiasis 8, is not the recommended regimen for oral thrush, though it has shown efficacy in some palliative care settings 9.