What is the treatment for oral thrush?

Treatment of Oral Thrush

For mild oral thrush, start with clotrimazole troches 10 mg five times daily for 7-14 days, and for moderate to severe disease, use oral fluconazole 100-200 mg daily for 7-14 days. 1, 2

Treatment Algorithm by Disease Severity

Mild Oral Thrush

• Clotrimazole troches 10 mg five times daily for 7-14 days is the preferred first-line topical therapy 1, 2
• Miconazole mucoadhesive buccal tablet 50 mg once daily for 7-14 days applied to the mucosal surface over the canine fossa offers a convenient once-daily alternative 1, 2
• Nystatin suspension 4-6 mL (400,000-600,000 units) four times daily for 7-14 days is an option, but has lower efficacy (32-54% cure rates) compared to fluconazole (100% cure rates in infants) 3, 4
• When using nystatin, instruct patients to swish and hold in the mouth for at least 2 minutes before swallowing 3

Moderate to Severe Oral Thrush

• Oral fluconazole 100-200 mg daily for 7-14 days is the gold standard treatment with superior efficacy to topical agents 1, 2, 3
• Fluconazole is significantly more effective than nystatin, with clinical cure rates of 100% versus 32% in comparative studies 4
• Continue treatment until clinical resolution of symptoms 2

Fluconazole-Refractory Disease

For patients who fail fluconazole therapy, escalate to second-line systemic agents 1, 2:

• Itraconazole solution 200 mg once daily for up to 28 days (effective in approximately two-thirds of fluconazole-refractory cases) 2, 3
• Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 1, 2
• Voriconazole 200 mg twice daily 2
• Amphotericin B deoxycholate oral suspension 100 mg/mL four times daily 2

Patients Unable to Tolerate Oral Therapy

When patients cannot swallow medications 2:

• Intravenous fluconazole 400 mg (6 mg/kg) daily is the preferred parenteral option 2
• Intravenous echinocandins (caspofungin, micafungin, or anidulafungin) are effective alternatives 2
• Intravenous amphotericin B deoxycholate 0.3 mg/kg daily is a less preferred option reserved for otherwise unresponsive infections 5, 2

Special Clinical Situations

Denture-Related Candidiasis

• Always disinfect dentures in addition to antifungal therapy 1, 2
• Remove dentures at night and clean thoroughly 2
• Failure to address denture hygiene will result in treatment failure regardless of antifungal choice 1

Recurrent Infections

• Fluconazole 100 mg three times weekly for chronic suppressive therapy in patients with frequent recurrences 1, 2, 3
• For HIV-infected patients, antiretroviral therapy is critically important to reduce recurrence rates and is more important than the choice of antifungal 1, 2, 3
• In HIV patients, oral thrush may indicate disease progression and low CD4 counts 1

Critical Clinical Pearls

Resistance Considerations

• Fluconazole resistance may develop with prolonged or repeated exposure, particularly in immunocompromised patients 1
• Resistance typically occurs after multiple treatment courses in patients with AIDS or advanced immunosuppression 5

Underlying Conditions to Address

• Always evaluate for predisposing factors: diabetes, immunosuppression, corticosteroid use, recent antibiotic therapy, or inhaled corticosteroids 1
• Single-dose fluconazole 150 mg has shown 96.5% efficacy in palliative care patients with advanced cancer, offering a pill burden-reducing option 6

Common Pitfalls to Avoid

• Do not use topical therapy alone for moderate to severe disease or in immunocompromised patients due to inferior efficacy 3
• Topical nystatin is completely inadequate for esophageal candidiasis and requires systemic therapy 3
• Treatment duration should extend at least 48 hours after symptoms disappear and cultures confirm eradication 3