What are alternative treatments for oral candidiasis (thrush) in a 90-year-old female (F) when oral Nystatin (nystatin) is ineffective?

From the Guidelines

For a 90-year-old female with thrush unresponsive to oral nystatin, fluconazole is the recommended next step, typically 200–400 mg (3–6 mg/kg) daily, for 14–21 days, as per the guidelines from the Infectious Diseases Society of America 1.

Key Considerations

• The patient's age and potential comorbidities should be taken into account when selecting an antifungal agent, with careful consideration of potential drug interactions, particularly with fluconazole 1.
• Clotrimazole troches (10mg) dissolved in the mouth 5 times daily for 7-14 days are an alternative if systemic therapy is contraindicated, as recommended by the guidelines 1.
• For patients with dentures, removing them at night and soaking in chlorhexidine solution is essential, as dentures can harbor Candida, and disinfection of the denture, in addition to antifungal therapy, is recommended 1.

Treatment Approach

• Oral fluconazole, 200–400 mg (3–6 mg/kg) daily, for 14–21 days is recommended for the treatment of thrush in this patient population, as it is a strong recommendation with high-quality evidence 1.
• In cases where fluconazole is not effective, alternatives such as itraconazole solution, 200 mg daily, or voriconazole, 200 mg (3 mg/kg) twice daily, either intravenous or oral, for 14–21 days, can be considered 1.
• Addressing underlying risk factors is crucial, including reviewing medications that may cause dry mouth, ensuring adequate hydration, and considering vitamin supplements if nutritional deficiencies are present.

Monitoring and Follow-up

• Elderly patients may need longer treatment courses due to age-related immune changes, and medication interactions must be carefully monitored, particularly with fluconazole, which can interact with warfarin, statins, and certain antihypertensives commonly used in this age group 1.

From the FDA Drug Label

Clinical and mycological response rates were higher in the children treated with fluconazole. Clinical cure at the end of treatment was reported for 86% of fluconazole-treated patients compared to 46% of nystatin treated patients Mycologically, 76% of fluconazole treated patients had the infecting organism eradicated compared to 11% for nystatin treated patients.

For a 90-year-old female patient with thrush who is not responding to oral nystatin, fluconazole may be considered as an alternative treatment option. The dosage for oropharyngeal candidiasis is not explicitly stated in the provided drug label for this patient population, but based on the available information, fluconazole may be effective in treating thrush. However, it is essential to consult the prescribing information and consider the patient's overall health status, potential interactions, and renal function before initiating treatment 2.

• Key points:
  • Fluconazole may be effective in treating oropharyngeal candidiasis
  • Clinical cure rates were higher with fluconazole compared to nystatin
  • Consider patient's overall health status and potential interactions before initiating treatment
• Alternative option: Itraconazole oral solution may also be considered for the treatment of oropharyngeal candidiasis, with a recommended dosage of 200 mg (20 mL) daily for 1 to 2 weeks 3.

From the Research

Treatment Options for Thrush in a 90-Year-Old Female

When oral nystatin is not effective, several alternative treatment options can be considered:

• Topical antifungal drugs such as miconazole, which is effective but may interact with other drugs 4
• Oral fluconazole, which is effective in treating oral candidiasis that does not respond to topical treatment 4
• Other systemic treatment alternatives, such as itraconazole, voriconazole, or posaconazole, which are less commonly used 4
• Newer antifungal agents, such as echinocandins (anidulafungin, caspofungin) or isavuconazole, which are available for oral or intravenous use 4, 5

Considerations for Treatment

When selecting a treatment option, it is essential to consider the following factors:

• The patient's medical history and current medications to minimize potential drug interactions 4, 6
• The severity of the infection and the patient's overall health status 5, 7
• The potential for resistance to antifungal drugs, which can be a concern with repeated or prolonged use 8

Alternative Antifungal Agents

Other antifungal agents that may be considered for treatment include:

• Amphotericin B, which is effective but may not be available in all countries 4, 5
• Clotrimazole, which is a topical antifungal agent that may be used as an alternative to nystatin 4, 5
• Ibrexafungerp, which is a new antifungal agent that may be used for treatment 4