What is the treatment for recurrent thrush?

Treatment for Recurrent Thrush

For patients with recurrent thrush, fluconazole 100 mg three times weekly is the recommended chronic suppressive therapy regimen to prevent recurrent episodes. 1

Initial Treatment Based on Severity

• For mild oropharyngeal thrush:

  • First-line: Clotrimazole troches (10 mg 5 times daily) or miconazole mucoadhesive buccal 50-mg tablet applied once daily for 7-14 days 1
  • Alternative: Nystatin suspension (100,000 U/mL) 4-6 mL 4 times daily, or 1-2 nystatin pastilles (200,000 U each) 4 times daily, for 7-14 days 1

• For moderate to severe oropharyngeal thrush:

  • Oral fluconazole 100-200 mg daily for 7-14 days 1
  • Single-dose fluconazole 150 mg has also shown effectiveness in palliative care patients (96.5% improvement) 2

Management of Recurrent Episodes

For Oropharyngeal Thrush

• After initial treatment and clearance of infection, chronic suppressive therapy with fluconazole 100 mg three times weekly is strongly recommended for patients with recurrent infection 1
• For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce recurrence 1
• For denture-related candidiasis, proper disinfection of the denture in addition to antifungal therapy is essential 1

For Recurrent Vulvovaginal Candidiasis

• Initial control of acute episode followed by fluconazole 150 mg weekly for 6 months 1, 3
  • This regimen has shown significant effectiveness with 90.8% of women remaining disease-free at 6 months compared to 35.9% with placebo 3
• Alternative: Monthly cycle-dependent itraconazole (200 mg twice daily for one day per month) for 6 months 4

For Fluconazole-Refractory Cases

• For oropharyngeal thrush resistant to fluconazole:
  • Itraconazole solution 200 mg once daily OR posaconazole suspension 400 mg twice daily for 3 days then 400 mg daily, for up to 28 days 1
  • Alternatives include voriconazole 200 mg twice daily OR amphotericin B deoxycholate oral suspension 100 mg/mL 4 times daily 1
  • For severe refractory cases: Intravenous echinocandin (caspofungin, micafungin, or anidulafungin) OR intravenous amphotericin B deoxycholate 0.3 mg/kg daily 1

Special Considerations

• Identify and address predisposing factors:

  • For denture wearers: Proper denture hygiene and disinfection 1
  • For immunocompromised patients: Treat underlying immunodeficiency when possible 1
  • For diabetic patients: Optimize glycemic control 1

• Monitor for development of resistance:

  • Long-term azole therapy can potentially lead to resistance, though studies show no evidence of fluconazole resistance in Candida albicans with weekly prophylactic regimens 3

Duration of Therapy

• For acute episodes: 7-14 days for oropharyngeal thrush 1
• For suppressive therapy: Initially 6 months for vulvovaginal candidiasis 3
• For recurrent oropharyngeal thrush: Continued suppression may be needed indefinitely in patients with persistent immunosuppression 1

Pitfalls and Caveats

• Failure to identify and address underlying causes may lead to treatment failure 1
• Improper denture care can lead to persistent colonization and recurrent infection 1
• Non-albicans Candida species may be less responsive to fluconazole and require alternative therapies 1
• Patients on long-term suppressive therapy should be monitored for potential drug interactions and hepatotoxicity 1