What is the treatment for thrush in adults?

Treatment of Thrush in Adults

For oral thrush in adults, first-line treatment is fluconazole 100-200 mg daily for 7-14 days, or topical agents such as clotrimazole troches 10 mg five times daily for 7-14 days. 1, 2

Diagnosis

Thrush (oral candidiasis) is a fungal infection of the oral cavity, typically caused by Candida albicans. Diagnosis is usually made clinically by identifying:

• White, curd-like plaques on the oral mucosa, tongue, or palate
• Erythematous patches on the oral mucosa
• Symptoms may include burning sensation, altered taste, and discomfort

Treatment Options

First-line treatments:

1. Mild disease:

   • Clotrimazole troches 10 mg 5 times daily for 7-14 days 1
   • Miconazole mucoadhesive buccal 50-mg tablet applied 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

2. Moderate to severe disease:

   • Oral fluconazole 100-200 mg daily for 7-14 days 1, 2
   • Single-dose fluconazole 150 mg has shown efficacy in palliative care patients with 96.5% showing improvement 3

For fluconazole-refractory disease:

• Itraconazole solution 200 mg once daily for up to 28 days 1, 2
• Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 1, 2
• Voriconazole 200 mg twice daily 1, 2, 4
• Amphotericin B oral suspension 100 mg/mL 4 times daily 1

For severe refractory cases:

• Intravenous echinocandin (e.g., caspofungin: 70-mg loading dose, then 50 mg daily) 1, 2
• Intravenous amphotericin B deoxycholate (0.3 mg/kg daily) 1, 2

Treatment Duration

• Standard treatment duration is 7-14 days 1, 2
• Treatment should continue until clinical resolution of symptoms
• For immunocompromised patients, longer treatment may be necessary 1, 2

Special Considerations

Denture-related candidiasis:

• Remove and clean dentures daily in addition to antifungal therapy 2
• Soak dentures in antifungal solution overnight

HIV/AIDS patients:

• May require longer treatment durations 1
• May need maintenance therapy to prevent relapse 1
• Fluconazole has shown better efficacy than clotrimazole in HIV patients 5

Esophageal candidiasis:

• Requires systemic therapy with fluconazole 200-400 mg daily for 14-21 days 1, 2
• Alternatives include voriconazole or echinocandins for resistant cases 4

Prevention

• Good oral hygiene practices
• Remove and clean dentures daily
• Rinse mouth after using inhaled corticosteroids
• Avoid unnecessary antibiotics
• Control underlying conditions (diabetes, immunosuppression)

Monitoring

• Assess clinical response within 3-5 days of treatment initiation 2
• Monitor liver function tests if treatment extends beyond 7-10 days 2
• If no improvement after 7-14 days, consider alternative diagnosis or resistant organisms

Potential Adverse Effects

• Azoles: Gastrointestinal upset, hepatotoxicity, drug interactions 6
• Nystatin/clotrimazole: Minimal systemic absorption, generally well-tolerated
• Voriconazole: Visual disturbances, hepatotoxicity, photosensitivity 4, 6

Thrush is generally responsive to appropriate antifungal therapy, with most patients experiencing rapid improvement within 48-72 hours of treatment initiation 1.