What are the alternative treatment options for a 15-month-old child with persistent oral candidiasis (thrush) unresponsive to repeated antifungal medication, causing discomfort and distress?

From the Guidelines

I strongly recommend switching to fluconazole oral suspension at a dose of 3-6 mg/kg once daily for 14-21 days for this persistent oral thrush case, as suggested by the most recent and highest quality study 1. The repeated treatment failures with the same medication suggest possible resistance to the current antifungal agent, likely nystatin.

Key Considerations

• For immediate relief, the caregiver should clean the child's mouth gently with a soft cloth and water before medication application.
• Since the child is 15 months old, it is essential to evaluate for any underlying immune issues that may be contributing to the persistence of the infection.
• The child's eating difficulties are concerning and could affect nutrition and development.

Treatment Options

• Fluconazole works differently than topical antifungals by inhibiting fungal cell membrane synthesis systemically, which may be more effective for persistent infections.
• The caregiver should monitor for any side effects such as vomiting, diarrhea, or rash, and seek immediate medical attention if these occur.
• If the child cannot tolerate oral therapy, intravenous fluconazole or an echinocandin may be considered as alternative options, as recommended by 1.

Additional Recommendations

• Consider requesting a referral to a pediatric infectious disease specialist to evaluate the child's condition and provide further guidance on management.
• Chronic suppressive therapy with fluconazole may be necessary if the child experiences recurrent infections, as suggested by 1.

From the FDA Drug Label

Oropharyngeal candidiasis: The recommended dosage of fluconazole tablets for oropharyngeal candidiasis in children is 6 mg/kg on the first day, followed by 3 mg/kg once daily. Treatment should be administered for at least 2 weeks to decrease the likelihood of relapse Esophageal candidiasis: For the treatment of esophageal candidiasis, the recommended dosage of fluconazole tablets in children is 6 mg/kg on the first day, followed by 3 mg/kg once daily. Doses up to 12 mg/kg/day may be used, based on medical judgment of the patient’s response to therapy Systemic Candida infections: For the treatment of candidemia and disseminated Candida infections, daily doses of 6 to 12 mg/kg/day have been used in an open, noncomparative study of a small number of children

The alternative treatment options for a 15-month-old child with persistent oral candidiasis unresponsive to repeated antifungal medication are:

• Increasing the dose of fluconazole up to 12 mg/kg/day based on medical judgment of the patient's response to therapy 2
• Considering other antifungal medications not mentioned in the label, as the current treatment has been ineffective
• Consulting a pediatric specialist or an infectious disease expert for further guidance on treatment options 2

From the Research

Alternative Treatment Options for Persistent Oral Candidiasis

• For a 15-month-old child with persistent oral candidiasis unresponsive to repeated antifungal medication, alternative treatment options can be considered, as suggested by studies 3, 4, 5, 6.
• Fluconazole has been shown to be effective in treating oral candidiasis that does not respond to topical treatment, with a clinical cure rate of 100% in one study 3 and 91% in another study 5.
• Miconazole gel has also been found to be effective in treating oropharyngeal candidiasis in immunocompetent infants, with a clinical cure rate of 96.9% by Day 8 of treatment 6.
• Other systemic treatment alternatives, such as itraconazole, voriconazole, or posaconazole, may also be considered for recalcitrant infections 4.
• Newer antifungal drugs, such as echinocandins (anidulafungin, caspofungin) and isavuconazole, may also be effective in treating oral candidiasis, although more research is needed to confirm their efficacy 4.

Considerations for Treatment

• The choice of treatment should be based on the severity of the infection, the patient's immune status, and the potential for drug interactions 7.
• Topical antifungal agents, such as nystatin and miconazole, may be effective for mild to moderate infections, but may require a longer duration of treatment to eradicate the infection 4, 6.
• Systemic antifungal agents, such as fluconazole and itraconazole, may be more effective for severe or recalcitrant infections, but may have a higher risk of side effects and drug interactions 4, 5, 7.