What is the treatment for oral thrush?

Treatment of Oral Thrush

For oral thrush treatment, fluconazole is recommended at 200 mg on the first day, followed by 100 mg once daily for 7-14 days, as it demonstrates superior efficacy compared to topical agents. 1

First-Line Treatment Options

Systemic Therapy

• Fluconazole (preferred):
  • Standard regimen: 200 mg on day 1, then 100 mg daily for 7-14 days 1
  • Single-dose option: 150 mg as a one-time dose (96.5% efficacy in palliative care patients) 2
  • Continue treatment for at least 48 hours after symptom resolution 1

Topical Therapy

• Nystatin oral suspension: FDA-approved for oral candidiasis 3

  • Typically administered as a "swish and swallow" 4 times daily for 7-14 days
  • Note: Clinical cure rates are significantly lower (32%) compared to fluconazole (100%) 4

• Clotrimazole troches:

  • Dissolve in mouth over 30 minutes
  • Repeat every 3 hours to maintain therapeutic levels 5

Treatment Algorithm Based on Disease Severity

Mild-Moderate Disease

1. First choice: Fluconazole 200 mg on day 1, then 100 mg daily for 7-14 days 1
2. Alternative: Topical agents (nystatin suspension or clotrimazole troches) if fluconazole is contraindicated

Severe Disease or Immunocompromised Patients

1. First choice: Fluconazole 200 mg on day 1, then 100-200 mg daily for 14 days 1
2. Alternatives:
   • Itraconazole solution (200 mg daily for up to 28 days)
   • Posaconazole suspension (400 mg twice daily for 3 days, then 400 mg daily)
   • Voriconazole (200 mg twice daily) 1
3. For severe cases or when oral administration isn't feasible:
   • IV fluconazole (loading dose 400 mg, then 200-400 mg daily)
   • IV echinocandins (caspofungin, micafungin, or anidulafungin)
   • IV amphotericin B deoxycholate 1

Monitoring and Follow-up

• Assess clinical response within 3-5 days of treatment initiation 1
• Monitor liver function tests if azole treatment extends beyond 7-10 days 1
• Continue treatment for at least 48 hours after symptom resolution 1

Management of Recurrent Infections

• For recurrent infections: Fluconazole 100 mg three times weekly as chronic suppressive therapy 1
• Address underlying risk factors (uncontrolled diabetes, immunosuppression) 1
• For HIV/AIDS patients: Initiate antiretroviral therapy to reduce recurrence risk 1

Prevention Strategies

• Maintain good oral hygiene
• Remove and clean dentures daily
• Use chlorhexidine 0.2% solution for regular oral care
• Avoid unnecessary antibiotics when possible 1

Clinical Pearls

• Fluconazole has demonstrated superior efficacy (100%) compared to nystatin (32%) in controlled studies 4
• Single-dose fluconazole 150 mg can be effective in palliative care patients, reducing pill burden 2
• Topical agents require more frequent administration and have lower cure rates but may be appropriate for patients who cannot take systemic therapy
• Candida albicans is the most common cause of oral thrush but other Candida species may require different treatment approaches 6
• Prompt diagnosis and treatment are essential to prevent complications, especially in immunocompromised patients 1