What is the treatment for oral thrush?

Treatment of Oral Thrush

Fluconazole is the preferred treatment for moderate to severe oral thrush, with a standard regimen of 200 mg on day 1, followed by 100 mg daily for 7-14 days. 1

First-Line Treatment Options

Systemic Antifungals

• Fluconazole:
  • Standard regimen: 200 mg on day 1, then 100 mg daily for 7-14 days 1
  • For severe cases: IV fluconazole with loading dose of 400 mg (6 mg/kg) and maintenance dose of 200-400 mg daily for 14-21 days 1
  • For palliative care patients: Single-dose fluconazole 150 mg has shown 96.5% improvement in signs and symptoms 2

Topical Antifungals

• Nystatin oral suspension: FDA-approved for treatment of oral candidiasis 3
  • Note: Clinical evidence shows lower efficacy compared to systemic options, with studies showing only 32% cure rates compared to 100% for fluconazole 4
• Clotrimazole troches: Provides sustained antifungal concentrations in saliva for up to three hours 5

Alternative Treatment Options

• Itraconazole solution: 200 mg once daily 1
• Posaconazole suspension: 400 mg twice daily for 3 days, then 400 mg daily 1
• Voriconazole: 200 mg twice daily 1
• Miconazole gel: Has shown superior efficacy to nystatin suspension in clinical studies 6

Treatment Algorithm Based on Severity

1. Mild to Moderate Oral Thrush:

   • First choice: Topical agents (nystatin suspension or clotrimazole troches)
   • Alternative: Single-dose fluconazole 150 mg (especially beneficial in palliative care settings) 2

2. Moderate to Severe Oral Thrush:

   • First choice: Fluconazole 200 mg on day 1, then 100 mg daily for 7-14 days 1
   • Alternatives: Itraconazole, posaconazole, or voriconazole 1

3. Severe Cases or NPO Patients:

   • IV fluconazole or echinocandins (caspofungin, micafungin, or anidulafungin) 1
   • Amphotericin B deoxycholate for refractory cases 1

Management of Recurrent Infections

• Chronic suppressive therapy with fluconazole 100 mg three times weekly 1
• Address underlying risk factors:
  • Uncontrolled diabetes
  • Immunosuppression
  • Poor oral hygiene
  • Ill-fitting dentures 1
• For HIV-infected patients: Antiretroviral therapy is strongly recommended 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 14 days and for at least 48 hours after symptom resolution 1

Prevention and Supportive Care

• Maintain good oral hygiene
• Remove and clean dentures daily
• Avoid unnecessary antibiotics
• Regular oral care with chlorhexidine 0.2% solution 1

Special Considerations

• Immunocompromised patients: Longer treatment duration and closer follow-up required; systemic therapy preferred over topical agents 1
• Infants: Fluconazole suspension (3 mg/kg daily for 7 days) has shown superior efficacy to nystatin suspension 4
• Palliative care patients: Single-dose fluconazole 150 mg may be particularly beneficial to reduce pill burden 2

Common Pitfalls to Avoid

1. Inadequate treatment duration: Ensure full course completion even after symptoms resolve
2. Neglecting underlying conditions: Always address predisposing factors to prevent recurrence
3. Overreliance on topical agents: For moderate to severe cases, systemic therapy is more effective
4. Failure to monitor for drug interactions: Azoles have significant drug interaction potential