What is the treatment for a patient with oral thrush?

Treatment for Oral Thrush

For oral thrush, fluconazole 100-200 mg daily for 7-14 days is the recommended first-line treatment due to its high efficacy and convenience of once-daily dosing. 1

First-line Treatment Options

Systemic Antifungals

• Fluconazole: 100-200 mg daily for 7-14 days
  • Highest clinical cure rate with convenient once-daily dosing
  • Particularly effective for moderate to severe cases
  • Superior patient compliance compared to multiple daily dose regimens 2

Topical Antifungals

• Nystatin suspension: 100,000 U/mL, 4-6 mL four times daily for 7-14 days 1
• Clotrimazole troches: 10 mg five times daily for 7-14 days 1, 3
• Miconazole mucoadhesive buccal tablets: 50 mg once daily for 7-14 days 1

Treatment Algorithm

1. Assess severity and patient factors:

   • Mild to moderate localized thrush → Topical agents
   • Extensive or severe thrush → Systemic fluconazole
   • Immunocompromised patients → Consider systemic therapy first

2. First-line therapy:

   • Immunocompetent patients with mild disease: Topical therapy (nystatin or clotrimazole)
   • Moderate to severe disease or immunocompromised: Fluconazole 100-200 mg daily

3. For refractory cases:

   • Itraconazole solution 200 mg daily for 7-14 days 1, 4
   • Can increase to >200 mg/day for resistant cases
   • Solution form has better absorption than capsules 1

Special Considerations

• Denture wearers: Thorough disinfection of dentures is essential alongside antifungal therapy 1
• HIV patients: Should receive antiretroviral therapy to reduce recurrence 1
• Diabetic patients: Optimize blood glucose management 1
• Patients using inhaled corticosteroids: Should rinse mouth after use to prevent recurrence 1

Evidence Comparison

Fluconazole has demonstrated superior efficacy compared to other treatments:

• 96.5% of palliative care patients showed >50% improvement with a single 150 mg dose 5
• 100% clinical cure rate with fluconazole vs. 32% with nystatin in infants 6
• 91% cure rate with fluconazole vs. 51% with nystatin in immunocompromised children 7

Monitoring and Follow-up

• Evaluate clinical response within 3-5 days of treatment initiation 1
• Monitor liver function tests if treatment extends beyond 7-10 days 1
• For patients with frequent recurrences, consider suppressive therapy with fluconazole 100 mg daily or 100 mg three times weekly 1

Common Pitfalls to Avoid

• Failure to address underlying causes: Identify and manage predisposing factors such as immunosuppression, diabetes, or denture issues
• Inadequate treatment duration: Complete the full course even if symptoms improve quickly
• Multiple courses of azole therapy: Increases risk of developing resistant strains (C. glabrata and C. krusei) 1
• Missing the diagnosis: Oral thrush can be confused with other white lesions, requiring careful examination 8