What is the recommended treatment for thrush in an inpatient setting?

Treatment of Oral Thrush in Inpatient Settings

For inpatient treatment of oral thrush, fluconazole is the preferred first-line therapy at a dose of 200 mg on day 1, followed by 100 mg daily for 7-14 days. 1

First-Line Treatment Options

For Mild to Moderate Oral Thrush:

• Fluconazole: 200 mg loading dose on day 1, then 100 mg daily for 7-14 days 1
• Alternative topical options:
  • Clotrimazole troches: 10 mg 5 times daily for 7-14 days 1
  • Miconazole mucoadhesive buccal tablet: 50 mg applied to mucosal surface once daily for 7-14 days 1
  • Nystatin suspension: 100,000 U/mL, 4-6 mL 4 times daily for 7-14 days 1
  • Nystatin pastilles: 200,000 U each, 1-2 pastilles 4 times daily for 7-14 days 1

For Severe or Refractory Oral Thrush:

• Intravenous options:
  • Echinocandins: caspofungin (70 mg loading dose, then 50 mg daily), micafungin (100 mg daily), or anidulafungin (200 mg loading dose, then 100 mg daily) 2, 1
  • Amphotericin B deoxycholate: Consider for severe cases when other options aren't feasible 1

Treatment Considerations for Special Populations

Immunocompromised Patients:

• Systemic therapy (fluconazole) is preferred over topical agents 1
• Longer treatment duration may be required 1
• For HIV/AIDS patients with recurrent infections, consider chronic suppressive therapy with fluconazole 100 mg three times weekly 1

For Patients with Fluconazole Resistance:

• Salvage therapy options:
  • Itraconazole solution: 200 mg once daily for up to 28 days 1
  • Posaconazole suspension: 400 mg twice daily for 3 days then 400 mg daily for up to 28 days 1
  • Voriconazole: 200 mg twice daily 1
  • Echinocandins (as mentioned above) 2

Monitoring and Follow-up

• Improvement typically occurs within 48-72 hours 1
• Complete resolution usually occurs within 7-14 days 1
• If no improvement after 7 days, consider:
  • Alternative diagnoses
  • Resistant Candida species
  • Need for longer treatment duration
  • Alternative antifungal agents 1
• Continue treatment for at least 14 days and for at least 48 hours after symptom resolution 1
• Monitor liver function tests if azole treatment extends beyond 7-10 days 1

Supportive Care Measures

• Implement strict oral hygiene protocols:
  • Regular oral care with chlorhexidine 0.2% solution
  • Careful cleaning of dentures (if applicable)
  • Daily inspection of oral mucosa 1
• Ensure adequate nutritional support:
  • Consider appropriate feeding route (nasogastric or PEG/PEJ tube) if needed
  • Consult dietitian for patient-specific nutritional needs 1
• Rinse mouth after using inhaled corticosteroids to prevent recurrence 2

Prevention of Recurrence

• Maintain good oral hygiene
• Remove and clean dentures daily (if applicable)
• Avoid unnecessary antibiotics when possible 1
• For patients with recurrent infections, consider chronic suppressive therapy with fluconazole 1

Clinical Pearls and Pitfalls

• Single-dose fluconazole 150 mg has shown efficacy in palliative care patients with oral thrush, which may be considered for patients with high pill burden 3
• Be vigilant about fluconazole resistance, especially in patients with HIV/AIDS or those on prolonged azole therapy 4, 5
• Oral thrush can progress to invasive candidiasis in severely immunocompromised patients, so prompt and effective treatment is essential 4
• The mouth should be rinsed out after nebulizing steroids and antibiotics to prevent development of oral thrush 2

By following these guidelines, inpatient oral thrush can be effectively managed with appropriate antifungal therapy and supportive care measures, reducing morbidity and improving patient comfort and oral intake.