What is the diagnosis and treatment for oral candidiasis (thrush)?

From the Guidelines

Oral candidiasis, commonly known as thrush, is best treated with antifungal medications, with oral fluconazole being a highly effective option for mild to moderate cases, as well as more severe or resistant cases, as evidenced by studies such as 1 and 1. The diagnosis of oral candidiasis typically involves clinical evaluation, including visual examination of the oral cavity and assessment of symptoms such as white patches on the tongue and inside of the mouth, redness, and soreness.

Treatment Options

• For mild to moderate cases, topical treatments like nystatin suspension or clotrimazole troches are effective first-line options, as recommended by 1 and 1.
• For more severe or resistant cases, oral fluconazole (100 mg/day for 7–14 days) is as effective as—and, in some studies, superior to—topical therapy, as noted in 1 and 1.
• Itraconazole solution (200 mg/day for 7–14 days) is as efficacious as fluconazole, according to 1 and 1.

Management and Prevention

• During treatment, maintaining good oral hygiene by brushing teeth twice daily, cleaning dentures thoroughly if worn, and avoiding mouthwashes containing alcohol is crucial.
• Addressing underlying factors is also important, such as controlling blood sugar if diabetic, using a spacer with inhaled corticosteroids, and rinsing the mouth after use, as these factors can contribute to the development of oral candidiasis, as mentioned in the examples.
• Suppressive therapy is effective for preventing recurrent infections, as stated in 1 and 1, but should be used judiciously to minimize the risk of antifungal resistance.

Recurrence and Resistance

• Treatment failure is generally defined as signs and symptoms of oropharyngeal or esophageal candidiasis that persist for more than 7–14 days of appropriate therapy, as defined in 1.
• Fluconazole-refractory oropharyngeal candidiasis may respond to itraconazole solution or other alternative treatments, as discussed in 1 and 1.

From the FDA Drug Label

The recommended dosage of SPORANOX ® (itraconazole) Oral Solution for oropharyngeal candidiasis is 200 mg (20 mL) daily for 1 to 2 weeks. Clinical signs and symptoms of oropharyngeal candidiasis generally resolve within several days. For patients with oropharyngeal candidiasis unresponsive/refractory to treatment with fluconazole tablets, the recommended dose is 100 mg (10 mL) b.i. d. For esophageal candidiasis, the recommended dosage of SPORANOX ® Oral Solution is 100 mg (10 mL) daily for a minimum treatment of three weeks. Treatment should continue for 2 weeks following resolution of symptoms.

The diagnosis of oral candidiasis (thrush) is not explicitly stated in the provided drug labels. The treatment for oral candidiasis (thrush) is itraconazole oral solution, with a recommended dosage of 200 mg (20 mL) daily for 1 to 2 weeks for oropharyngeal candidiasis, and 100 mg (10 mL) daily for a minimum treatment of three weeks for esophageal candidiasis 2. Key points to consider:

• Dose and duration: The dose and duration of treatment may vary depending on the patient's response to therapy and the severity of the infection.
• Administration: The solution should be vigorously swished in the mouth (10 mL at a time) for several seconds and swallowed.
• Relapse: Patients may be expected to relapse shortly after discontinuing therapy.
• Caution: Caution should be exercised when administering itraconazole to patients with renal or hepatic impairment.

From the Research

Diagnosis of Oral Candidiasis

• Oral candidiasis is a common opportunistic infection that requires knowledge of various clinical presentations and management strategies for successful treatment 3
• The infection can range from superficial mucocutaneous overgrowths to invasive bloodstream infections with a high mortality rate 3
• Numerous local and systemic factors contribute to the development of candidiasis, including Candida albicans, C. tropicalis, C. glabrata, C. krusei, and many others 3

Treatment of Oral Candidiasis

• Antifungal agents are available in various forms, each with differing indications, dosing regimens, adverse effects, and drug interactions 3
• Topical antifungal drugs, such as nystatin and miconazole, are commonly used to treat oral candidiasis 4, 5
• Systemic treatment alternatives, such as oral fluconazole, itraconazole, voriconazole, or posaconazole, may be used for recalcitrant infections or when topical treatment is not effective 4, 5, 6
• Echinocandins, such as anidulafungin and caspofungin, and isavuconazole are newer treatment options for oral candidiasis 3, 4
• Patients with dental prostheses should be advised to disinfect the prosthesis routinely during the candidal treatment period to prevent reinfection 7

Treatment Options

• Nystatin and miconazole are very effective for treating oral candidiasis, but may require a long time of use to eradicate the infection 4
• Fluconazole is effective in treating oral candidiasis that does not respond to topical treatment and is considered the drug of choice for systemic treatment 5
• Itraconazole has been shown to be effective in treating oral candidosis, with a faster response rate and lower relapse rate compared to clotrimazole 6