What is the treatment for thrush?

Treatment of Thrush (Oral Candidiasis)

For thrush (oral candidiasis), first-line treatment is clotrimazole troches 10 mg five times daily or miconazole mucoadhesive buccal 50-mg tablet once daily for 7-14 days for mild disease, while moderate to severe disease should be treated with oral fluconazole 100-200 mg daily for 7-14 days. 1

Treatment Algorithm Based on Disease Severity

Mild Oral Thrush

• Clotrimazole troches, 10 mg 5 times daily for 7-14 days (strong recommendation; high-quality evidence) 1
• Miconazole mucoadhesive buccal 50-mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days (strong recommendation; high-quality evidence) 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 (strong recommendation; moderate-quality evidence) 1

Moderate to Severe Oral Thrush

• Oral fluconazole, 100-200 mg daily, for 7-14 days (strong recommendation; high-quality evidence) 1
• Fluconazole is FDA-approved for oropharyngeal and esophageal candidiasis 2
• Recent research shows that single-dose fluconazole 150 mg may be effective in palliative care patients with oral thrush, with 96.5% showing >50% improvement in signs and symptoms (useful for reducing pill burden in certain populations) 3

Fluconazole-Refractory Disease

• Itraconazole solution, 200 mg once daily for up to 28 days (strong recommendation; moderate-quality evidence) 1
• Posaconazole suspension, 400 mg twice daily for 3 days then 400 mg daily, for up to 28 days (strong recommendation; moderate-quality evidence) 1
• Alternatives: voriconazole, 200 mg twice daily, OR amphotericin B deoxycholate oral suspension, 100 mg/mL 4 times daily (strong recommendation; moderate-quality evidence) 1
• For severe refractory cases: IV echinocandin (caspofungin: 70-mg loading dose, then 50 mg daily; micafungin: 100 mg daily; or anidulafungin: 200-mg loading dose, then 100 mg daily) OR IV amphotericin B deoxycholate, 0.3 mg/kg daily (weak recommendation; moderate-quality evidence) 1

Special Considerations

Recurrent Infections

• Chronic suppressive therapy is usually unnecessary 1
• If required for patients with recurrent infection, fluconazole 100 mg 3 times weekly is recommended (strong recommendation; high-quality evidence) 1

HIV-Infected Patients

• Antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections (strong recommendation; high-quality evidence) 1

Denture-Related Candidiasis

• Disinfection of the denture, in addition to antifungal therapy is recommended (strong recommendation; moderate-quality evidence) 1
• Remove dentures at night and clean thoroughly 4

Mechanism of Action of Common Antifungals

• Azoles (fluconazole, itraconazole, voriconazole): Inhibit fungal cell membrane synthesis 5
• Clotrimazole: Alters permeability of fungal cell membranes; concentrations persist in saliva for up to three hours after dissolution of troche 6
• Polyenes (amphotericin B): Bind to ergosterol in fungal cell membranes 5
• Echinocandins (caspofungin, micafungin, anidulafungin): Inhibit cell wall synthesis 5

Clinical Pearls and Pitfalls

• Obtain specimens for fungal culture before initiating therapy to identify causative organisms, especially in refractory cases 2
• Be aware of drug-drug interactions with azoles, particularly fluconazole 5
• Monitor for adverse effects of azoles including visual disturbances (with voriconazole), elevations in liver enzymes, and skin rashes 5
• Candida albicans is the most common cause of oral thrush but resistance to azoles or echinocandins has been reported in some strains 7
• For esophageal candidiasis, systemic antifungal therapy is always required, typically with fluconazole 200-400 mg daily for 14-21 days 1
• Thrush can be a sign of immunosuppression, so consider underlying conditions, especially in recurrent cases 7