What is the treatment for thrush?

Treatment for Thrush

Fluconazole 100-200 mg daily for 7-14 days is the recommended first-line treatment for oral thrush, with clotrimazole troches or nystatin suspension as effective topical alternatives for initial episodes. 1

First-Line Treatment Options

Systemic Treatment:

• Fluconazole: 100-200 mg daily for 7-14 days
  • Advantages: Once-daily dosing improves compliance 2
  • Complete relief typically occurs within 7-14 days 1
  • Single-dose fluconazole 150 mg has shown 96.5% improvement in palliative care patients 3

Topical Alternatives:

• Clotrimazole troches: Effective alternative for initial episodes
• Nystatin suspension: Effective but associated with more frequent recurrences 4
• Miconazole: Available as topical preparation for external use 5

Treatment Algorithm

1. For immunocompetent patients with first episode:

   • Start with fluconazole 100-200 mg daily for 7-14 days
   • Alternative: Clotrimazole troches or nystatin suspension if azoles contraindicated

2. For refractory cases:

   • Extended treatment up to 28 days with:
     • Itraconazole solution (200 mg once daily)
     • Posaconazole suspension (400 mg twice daily for 3 days, then 400 mg daily)
     • Voriconazole (200 mg twice daily) 1

3. For severe refractory cases:

   • Consider IV echinocandins (e.g., caspofungin: 70-mg loading dose, then 50 mg daily)
   • IV amphotericin B deoxycholate (0.3 mg/kg daily) as last resort 1

Special Populations

Immunocompromised Patients:

• Require longer treatment duration and closer follow-up
• Systemic therapy preferred over topical agents
• HIV/AIDS patients may need maintenance therapy to prevent relapse 1

Pregnant Women:

• Topical imidazoles are more effective than nystatin
• Seven-day treatment more effective than shorter courses 6

Infants:

• Fluconazole suspension 3 mg/kg daily for 7 days has shown superior efficacy (100% cure rate) compared to nystatin suspension (32% cure rate) 4

Monitoring and Follow-up

• Assess clinical response within 3-5 days of treatment initiation
• Monitor liver function tests if treatment extends beyond 7-10 days
• Improvement typically occurs within 48-72 hours 1

Prevention Strategies

• Good oral hygiene practices
• Remove and clean dentures daily
• Avoid unnecessary antibiotics
• Rinse mouth after using inhaled corticosteroids
• For denture-related candidiasis: thorough disinfection of dentures in addition to antifungal therapy 1

Important Precautions

• Fluconazole requires dose adjustment in renal impairment (50% reduction if creatinine clearance <50 mL/min)
• Azoles have significant drug interactions that should be evaluated before prescribing
• When using topical treatments like miconazole, avoid tampons, douches, spermicides, or other vaginal products during treatment
• Do not have vaginal intercourse during treatment with vaginal preparations 5

Common Pitfalls

1. Inadequate treatment duration: Seven-day treatment is more effective than shorter courses, especially in pregnancy and immunocompromised patients 1, 6

2. Missing underlying conditions: Recurrent thrush may indicate diabetes, HIV infection, or other immunosuppressive conditions 5

3. Ignoring denture hygiene: Failure to disinfect dentures can lead to treatment failure and recurrence 1

4. Drug interactions: Azoles interact with many medications, particularly warfarin, requiring careful medication review 5