What is the recommended treatment for persistent oral candidiasis?

Treatment of Persistent Oral Candidiasis

For persistent oral candidiasis, oral fluconazole at a dosage of 100-200 mg daily for 7-14 days is the recommended first-line treatment, with itraconazole solution 200 mg daily being the preferred option for fluconazole-refractory cases. 1, 2

Treatment Algorithm Based on Disease Severity

Mild Oral Candidiasis

• Clotrimazole troches, 10 mg 5 times daily for 7-14 days 3, 1
• Nystatin suspension (100,000 U/mL), 4-6 mL four times daily for 7-14 days 3
• Nystatin pastilles (200,000 U each), 1-2 pastilles four times daily for 7-14 days 3

Moderate to Severe Oral Candidiasis

• Oral fluconazole, 100-200 mg (3 mg/kg) daily for 7-14 days 3, 1, 2
• For patients who cannot tolerate oral therapy, intravenous fluconazole at 400 mg daily can be used 3

Management of Fluconazole-Refractory Disease

First-line Options for Refractory Cases

• Itraconazole oral solution, 200 mg daily for up to 28 days (64-80% response rate) 3, 2, 4, 5
• Posaconazole suspension, 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 3, 2

Second-line Options for Refractory Cases

• Voriconazole, 200 mg twice daily (oral or IV) for 14-21 days 3, 2
• Amphotericin B oral suspension, 1 mL of 100 mg/mL suspension four times daily 3
• Intravenous echinocandins:
  • Micafungin: 150 mg daily 3, 2, 6
  • Caspofungin: 70-mg loading dose, then 50 mg daily 3, 2, 6
  • Anidulafungin: 200 mg daily 3, 2
• Intravenous amphotericin B deoxycholate: 0.3-0.7 mg/kg daily 3, 2

Special Considerations

Denture-Related Candidiasis

• Disinfection of dentures is essential in addition to antifungal therapy 3, 1, 2, 6
• Remove dentures at night and soak in antifungal solution 2
• Consider replacement of old dentures that may harbor fungal organisms 1

HIV-Infected Patients

• Antiretroviral therapy is strongly recommended to reduce recurrent infections 3, 1, 2
• For recurrent infections, suppressive therapy with fluconazole 100 mg three times weekly is recommended 3, 2
• Higher initial doses and longer treatment courses may be required 2

Prevention of Recurrence

• For patients with frequent recurrences, suppressive therapy with fluconazole 100-200 mg three times weekly is recommended 3, 2
• Address underlying risk factors (immunosuppression, diabetes, corticosteroid use) 7
• For denture wearers, proper denture hygiene and regular cleaning is essential 1, 2

Important Clinical Pitfalls to Avoid

• Do not discontinue therapy prematurely once symptoms resolve; complete the full course 1, 2
• Do not rely solely on cultures from respiratory secretions for diagnosis, as these have poor predictive value 3, 2
• Be aware that azole-refractory infections are more common in patients with prior azole use and severely immunocompromised patients 2
• For fluconazole-refractory cases, switching to another azole (like itraconazole) rather than increasing fluconazole dose is more effective 5
• Monitor liver function with prolonged azole therapy (>21 days) due to potential hepatotoxicity 3