Treatment of Oral Thrush (Oropharyngeal Candidiasis)
For mild oral thrush, start with clotrimazole troches 10 mg five times daily for 7-14 days, which is the first-line topical therapy with strong evidence supporting its efficacy. 1
First-Line Treatment for Mild Disease
Clotrimazole troches 10 mg dissolved slowly in the mouth 5 times daily for 7-14 days is the preferred initial treatment (strong recommendation; high-quality evidence) 1, 2
Miconazole mucoadhesive buccal tablet 50 mg applied once daily to the mucosal surface over the canine fossa for 7-14 days is an equally effective alternative first-line option 1, 2
These topical agents achieve salivary concentrations that inhibit Candida for up to 3 hours after dissolution, with repetitive dosing maintaining therapeutic levels 3
Alternative Topical Options for Mild Disease
If clotrimazole or miconazole are unavailable or not tolerated:
Nystatin suspension 100,000 U/mL, 4-6 mL swished and swallowed 4 times daily for 7-14 days (strong recommendation; moderate-quality evidence) 1, 2
Nystatin pastilles 200,000 U each, 1-2 pastilles 4 times daily for 7-14 days 1, 2
Treatment for Moderate to Severe Disease
For moderate to severe oral thrush (extensive involvement, difficulty eating/drinking, or immunocompromised patients), oral fluconazole 100-200 mg daily for 7-14 days is recommended over topical therapy (strong recommendation; high-quality evidence) 1, 2
Fluconazole provides systemic coverage and is more effective than topical agents in severe cases 1
A single 150 mg dose of fluconazole has shown 96.5% efficacy in palliative care patients with advanced cancer, though this is not standard guideline therapy 4
Fluconazole-Refractory Disease
If thrush persists despite fluconazole treatment:
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 1
Voriconazole 200 mg twice daily as an alternative 1
Amphotericin B deoxycholate oral suspension 100 mg/mL 4 times daily for resistant cases 1, 2
Severe Refractory Cases
For patients who cannot tolerate or fail oral therapy:
Intravenous echinocandin (caspofungin 70 mg loading dose, then 50 mg daily; micafungin 100 mg daily; or anidulafungin 200 mg loading dose, then 100 mg daily) 1
Intravenous amphotericin B deoxycholate 0.3 mg/kg daily (weak recommendation; moderate-quality evidence) 1
Special Considerations
Denture-Related Thrush
- Disinfection of dentures is essential in addition to antifungal therapy to prevent reinfection (strong recommendation; moderate-quality evidence) 1, 2
Recurrent Thrush
Chronic suppressive therapy with fluconazole 100 mg three times weekly should be considered only if recurrent infections occur after completing initial treatment (strong recommendation; high-quality evidence) 1, 2
In HIV-infected patients, antiretroviral therapy is strongly recommended to reduce recurrence (strong recommendation; high-quality evidence) 1
Prophylactic fluconazole 100 mg daily has been shown to prevent thrush in AIDS patients with negligible toxicity 5
Common Pitfalls to Avoid
Do not use shorter treatment courses (3-4 days) in immunocompromised patients—7-14 days is necessary for adequate clearance 1
Topical agents cure approximately 80-90% of cases when the full treatment course is completed, so emphasize adherence 2
Avoid azole therapy in patients already on azole prophylaxis due to resistance concerns 1
Ensure patients dissolve troches slowly rather than swallowing them whole, as local mucosal contact is essential for efficacy 3
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