What is the treatment for thrush?

Treatment of Thrush

For oropharyngeal candidiasis (thrush), fluconazole 100-200 mg daily for 7-14 days is the recommended first-line treatment, with clotrimazole troches as an effective alternative therapy. 1, 2

First-Line Treatment Options

Systemic Treatment

• Fluconazole:
  • Dosage: 100-200 mg daily 1, 2
  • Duration: 7-14 days for uncomplicated disease 1
  • Advantages: Once-daily dosing, high efficacy, better patient compliance 3
  • Particularly useful for moderate to severe cases or immunocompromised patients

Topical Treatment

• Clotrimazole troches:

  • Dosage: 10 mg 5 times daily 1
  • Duration: 7-14 days 1
  • Mechanism: Provides direct contact with infected tissues 4
  • Good option for mild cases or when systemic therapy is contraindicated

• Nystatin suspension or pastilles:

  • Dosage: 200,000-400,000 units 4 times daily 1
  • Duration: 7-14 days (1-7 days in children) 1
  • Particularly useful for infants or when azoles are contraindicated

Alternative Treatments for Refractory Cases

For patients with refractory disease or fluconazole resistance:

• Itraconazole solution: 200 mg daily 1
• Posaconazole: 400 mg daily 1
• Voriconazole: 200 mg twice daily 1
• Amphotericin B oral suspension: For severe cases 1
• Echinocandins (IV only): For severe cases with resistance to other agents 1

Single-Dose Option for Palliative Care

For palliative care patients or those with difficulty adhering to multi-day regimens:

• Single-dose fluconazole 150 mg has shown 96.5% improvement in signs and symptoms in hospice and palliative medicine patients 5

Treatment Algorithm

1. Assess severity and patient factors:

   • Mild to moderate thrush in immunocompetent patients → Topical therapy
   • Moderate to severe thrush or immunocompromised patients → Systemic therapy
   • Palliative care patients → Consider single-dose fluconazole

2. First-line treatment:

   • Fluconazole 100-200 mg daily for 7-14 days OR
   • Clotrimazole troches 10 mg 5 times daily for 7-14 days

3. For refractory cases (not responding within 7-14 days):

   • Switch to an alternative agent
   • Consider susceptibility testing if available
   • Evaluate for underlying conditions (HIV, diabetes, immunosuppression)

Important Considerations

• Mouth care: Rinse mouth after using topical agents or after meals
• Monitor for side effects: Check liver function tests when using prolonged courses of azoles 2
• Prevent recurrence: Address predisposing factors such as corticosteroid inhalers, antibiotics, or poorly controlled diabetes
• For patients using inhaled corticosteroids: Rinse mouth after each use to prevent thrush

Caution and Pitfalls

• Fluconazole resistance is increasing, particularly in patients with recurrent or prolonged exposure 6
• Untreated thrush in immunocompromised patients can potentially lead to esophageal candidiasis or even candidemia in severe cases 6
• Patients with HIV/AIDS may require longer treatment courses and more aggressive management 1
• Always rinse mouth after nebulizer therapy to prevent development of oral thrush 1

By following this treatment approach, most cases of thrush will resolve within 7-14 days. Persistent or recurrent cases warrant further investigation for underlying conditions or resistant organisms.