What is the treatment for oral thrush (Candidiasis)?

Treatment of Oral Thrush (Candidiasis)

For oral thrush (candidiasis), treatment should be based on disease severity, with topical antifungals for mild cases and systemic fluconazole for moderate to severe cases. 1

Treatment Algorithm Based on Severity

Mild Disease

• Clotrimazole troches, 10 mg 5 times daily for 7-14 days 1
• OR miconazole mucoadhesive buccal 50-mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days 1
• Alternative options include:
  • Nystatin suspension (100,000 U/mL) 4-6 mL 4 times daily for 7-14 days 1, 2
  • OR nystatin pastilles (200,000 U each) 1-2 pastilles 4 times daily for 7-14 days 1

Moderate to Severe Disease

• Oral fluconazole, 100-200 mg daily for 7-14 days 1
• This is strongly recommended with high-quality evidence 1

Fluconazole-Refractory Disease

• Itraconazole solution, 200 mg once daily for up to 28 days 1, 3
• OR posaconazole suspension, 400 mg twice daily for 3 days then 400 mg daily, for up to 28 days 1
• Alternative options:
  • Voriconazole, 200 mg twice daily 1
  • OR amphotericin B deoxycholate oral suspension, 100 mg/mL 4 times daily 1
  • For severe refractory cases: intravenous echinocandin or intravenous amphotericin B deoxycholate, 0.3 mg/kg daily 1

Special Considerations

Denture-Related Candidiasis

• Disinfection of the denture in addition to antifungal therapy is essential for cure 1
• Without proper denture hygiene, infection will likely recur 1

HIV-Infected Patients

• Antiretroviral therapy is strongly recommended to reduce recurrent infections 1
• These patients may require more aggressive initial therapy and are at higher risk for developing resistant infections 1

Recurrent Infections

• For patients with frequent recurrences, suppressive therapy with fluconazole 100 mg three times weekly is recommended 1
• However, chronic suppressive therapy is usually unnecessary for most patients 1

Medication Administration Tips

• Itraconazole solution should be vigorously swished in the mouth for several seconds before swallowing 3
• For optimal effect, itraconazole solution should be taken without food if possible 3
• Nystatin suspension should be swished in the mouth for as long as possible before swallowing 2

Evidence Comparison

• Fluconazole has shown superior clinical cure rates compared to clotrimazole troches in HIV patients 4
• In a study of infants, fluconazole suspension demonstrated 100% clinical cure rate compared to only 32% with nystatin suspension 5
• A 2017 study showed that even a single 150 mg dose of fluconazole was effective in treating oral thrush in palliative care patients, with 96.5% showing more than 50% improvement in signs and symptoms 6

Potential Pitfalls and Caveats

• Azole-refractory infections are more common in patients with prior azole use and severely immunocompromised patients 1
• Oropharyngeal fungal cultures are of little benefit as many individuals have asymptomatic colonization, and treatment frequently does not result in microbiological cure 1
• Itraconazole capsules are less effective than fluconazole or itraconazole solution due to variable absorption 1, 7
• For patients unable to tolerate oral medications, parenteral therapy should be used 1