What is the treatment for a throat infection suspected to be thrush?

Treatment of Oral Thrush (Oropharyngeal Candidiasis)

For oropharyngeal candidiasis (thrush), fluconazole 200 mg on the first day followed by 100 mg once daily for 7-14 days is the recommended first-line treatment due to its superior efficacy and convenience compared to topical therapies. 1, 2, 3

First-Line Treatment Options

Systemic Therapy

• Fluconazole (preferred):
  • Loading dose: 200 mg on day 1
  • Maintenance: 100 mg once daily for 7-14 days 1, 3
  • Continue treatment for at least 48 hours after symptom resolution 1
  • Single-dose fluconazole 150 mg has shown 96.5% improvement in palliative care patients 4

Topical Therapy Alternatives

• Clotrimazole troches: 10 mg 5 times daily for 7-14 days 2
• Nystatin suspension: 100,000 U/mL, 4-6 mL four times daily for 7-14 days 2, 1
• Nystatin pastilles: 200,000 U each, 1-2 pastilles 4-5 times daily for 7-14 days 1

For Fluconazole-Refractory Cases

1. Itraconazole solution: 200 mg daily for up to 28 days (64-80% effective in fluconazole-refractory cases) 2, 1

2. Voriconazole: 200 mg twice daily orally or intravenously for 14-21 days 2

3. Posaconazole suspension: 400 mg twice daily for 14-21 days 2, 1

4. Echinocandins (for severe cases):

   • Micafungin: 150 mg daily
   • Caspofungin: 70 mg loading dose, then 50 mg daily
   • Anidulafungin: 200 mg daily All for 14-21 days 2, 1

5. Amphotericin B deoxycholate: 0.3-0.7 mg/kg daily for 21 days (for severe refractory cases) 2

Important Clinical Considerations

Patient Instructions

• Swish oral suspensions in mouth for as long as possible before swallowing
• Administer after meals to prolong contact time with affected tissues
• For denture wearers:
  • Remove dentures before using antifungal medications
  • Clean dentures thoroughly daily
  • Soak dentures in antimicrobial solution (e.g., chlorhexidine 0.2% if available) 1

Management of Recurrent Infections

• Investigate underlying causes (immunosuppression, diabetes)
• For chronic suppressive therapy: fluconazole 100-200 mg three times weekly 2, 1
• For HIV-infected patients: antiretroviral therapy is strongly recommended to reduce recurrence 2, 1

Monitoring and Follow-up

• Schedule follow-up within 7-10 days to assess treatment response
• Monitor for hepatotoxicity if azole treatment extends beyond 7-10 days 1
• Most patients show improvement within 7 days of starting antifungal therapy 2

Clinical Pearls and Pitfalls

• Fluconazole has superior mycological cure rates compared to topical agents like clotrimazole (49% vs 27%) 5
• Patient compliance is significantly better with once-daily fluconazole compared to multiple daily doses of topical agents 6
• Recurrence following treatment often involves the same Candida strain (74% of cases) 5
• Long-term azole use can lead to development of resistant strains, particularly in immunocompromised patients 5
• Denture-related candidiasis requires both antifungal therapy and proper denture disinfection 2

Fluconazole is the treatment of choice for oropharyngeal candidiasis due to its high efficacy, once-daily dosing, and good systemic absorption, making it more convenient and effective than topical alternatives.