What is the treatment for esophageal thrush?

Treatment of Esophageal Thrush

Oral fluconazole 200-400 mg daily for 14-21 days is the first-line treatment for esophageal candidiasis (thrush), with a high clinical response rate. 1

First-Line Treatment

• Fluconazole 200-400 mg (3-6 mg/kg) daily for 14-21 days (oral route preferred)
  • Most patients experience symptom improvement within 48-72 hours
  • Complete resolution typically occurs within 7 days of starting therapy 1
  • High efficacy with excellent safety profile

Alternative Therapies (for patients who cannot tolerate oral therapy)

• Intravenous fluconazole 400 mg (6 mg/kg) daily 1
• Echinocandins (higher doses than for candidemia) 1
  • Micafungin: 150 mg daily
  • Caspofungin: 70 mg loading dose, then 50 mg daily
  • Anidulafungin: 200 mg daily
• Amphotericin B deoxycholate 0.3-0.7 mg/kg daily (less preferred due to toxicity) 1

For Fluconazole-Refractory Disease

1. Itraconazole oral solution 200 mg daily for 14-21 days 1, 2

   • Effective in approximately 80% of fluconazole-refractory cases 1
   • Should be swished in mouth and then swallowed 2
   • Take without food if possible 2

2. Voriconazole 200 mg (3 mg/kg) twice daily (oral or IV) for 14-21 days 1

3. Echinocandins (same doses as above) for 14-21 days 1

   • Note: Associated with higher relapse rates than fluconazole 1

4. Posaconazole suspension 400 mg twice daily or extended-release tablets 300 mg once daily (weaker recommendation) 1

5. Amphotericin B deoxycholate 0.3-0.7 mg/kg daily for 21 days 1

Diagnostic Approach

• A diagnostic trial of antifungal therapy is appropriate before performing endoscopy 1
• Presence of oral thrush with dysphagia or odynophagia is highly predictive of esophageal candidiasis 1, 3

Monitoring

• Monitor for clinical response within 7 days of starting therapy 1
• If prolonged azole therapy (>21 days) is anticipated, periodic liver function monitoring should be considered 1

For Recurrent Infections

• For patients with recurrent esophageal candidiasis, chronic suppressive therapy with fluconazole 100-200 mg three times weekly is recommended 1
• For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections 1

Special Considerations

• Echinocandins are effective but have higher relapse rates than fluconazole 1
• Itraconazole oral solution and capsules should not be used interchangeably; only the solution has been demonstrated effective for esophageal candidiasis 2
• Use caution with azoles in patients with hepatic impairment 2
• Drug interactions are common with azoles, particularly in patients on antiretroviral therapy

Clinical Pearls

• Most cases of esophageal candidiasis are caused by Candida albicans, but other species including C. glabrata, C. dubliniensis, and C. krusei can cause symptomatic infections 1
• Treatment failure is defined as persistent symptoms after 7-14 days of appropriate therapy
• Consider other causes of infectious esophagitis (HSV, CMV) if no response to antifungal therapy 4