What is the treatment for a significant oral candidiasis (yeast infection in the throat)?

Treatment of Significant Oral/Throat Candidiasis (Thrush)

For significant oral or esophageal candidiasis, oral fluconazole 200-400 mg daily for 14-21 days is the treatment of choice, with higher doses (400 mg) reserved for more severe infections or esophageal involvement. 1

Initial Treatment Approach

For Moderate to Severe Oral Thrush

• Fluconazole 200-400 mg (3-6 mg/kg) orally once daily for 14-21 days is the first-line therapy 1, 2
• The 400 mg dose should be used for esophageal involvement or severe disease 1
• Clinical response typically occurs within several days, but full treatment duration must be completed 2

For Patients Unable to Tolerate Oral Therapy

• Intravenous fluconazole 400 mg (6 mg/kg) daily is recommended 1
• Alternative: An echinocandin (micafungin 150 mg daily, caspofungin 70 mg loading then 50 mg daily, or anidulafungin 200 mg daily) 1
• Less preferred: Amphotericin B deoxycholate 0.3-0.7 mg/kg daily 1
• De-escalate to oral fluconazole once the patient can tolerate oral intake 1

Treatment for Fluconazole-Refractory Disease

This is critical for patients who fail initial fluconazole therapy or have prior azole exposure:

First-Line Alternatives

• Itraconazole oral solution 200 mg daily for 14-21 days (64-80% response rate) 1, 2, 3
  • Must use the oral solution formulation, not capsules, due to superior bioavailability 1, 3
  • Should be taken without food if possible 3
• Voriconazole 200 mg (3 mg/kg) twice daily (oral or IV) for 14-21 days 1, 2

Second-Line Alternatives

• Posaconazole suspension 400 mg twice daily (approximately 75% efficacy in refractory cases) 1, 2
  • Alternative: Extended-release tablets 300 mg once daily 1
• Echinocandins for severe refractory cases 1, 2:
  • Micafungin 150 mg daily
  • Caspofungin 70 mg loading dose, then 50 mg daily
  • Anidulafungin 200 mg daily
• Amphotericin B deoxycholate 0.3-0.7 mg/kg daily (less preferred due to toxicity) 1, 2

Important Clinical Considerations

What NOT to Use

• Topical agents (nystatin, amphotericin B lozenges) should NOT be used for significant infections due to suboptimal tolerability and lower efficacy 1
• Ketoconazole is NOT recommended due to hepatotoxicity and drug interactions 1
• Echinocandins should NOT be first-line for azole-susceptible disease due to parenteral administration and cost 1

Special Populations

• HIV-infected patients: Antiretroviral therapy is strongly recommended to reduce recurrent infections 1, 2
• For recurrent infections: Chronic suppressive therapy with fluconazole 100-200 mg three times weekly 1, 2
• Neutropenic patients: May require more aggressive therapy; persistent neutropenia is associated with worse outcomes 4

Denture-Related Candidiasis

• Proper denture hygiene and disinfection are essential in addition to antifungal therapy for definitive cure 2

Common Pitfalls to Avoid

• Do not stop treatment early even if symptoms resolve quickly; complete the full 14-21 day course 2
• Do not use fluconazole capsules and oral solution interchangeably with itraconazole—only itraconazole oral solution is effective for oropharyngeal/esophageal candidiasis 3
• Do not assume all Candida species are fluconazole-susceptible: C. krusei is intrinsically resistant, and C. glabrata often has reduced susceptibility 5
• Patients with prior azole exposure are at higher risk for azole-refractory infections 2
• Most patients will relapse shortly after discontinuing therapy if underlying immunosuppression is not addressed 3