What is the treatment for oral thrush in adults?

Treatment of Oral Thrush in Adults

For uncomplicated oral thrush in adults, oral fluconazole 100-200 mg daily for 7-14 days is the preferred first-line treatment, offering superior convenience and compliance compared to topical agents. 1

First-Line Treatment Options

Systemic Therapy (Preferred)

• Fluconazole 100-200 mg orally once daily for 7-14 days is the drug of choice for oropharyngeal candidiasis 1
• This regimen demonstrates superior efficacy and patient compliance compared to topical agents, particularly important in real-world practice 2
• For a single-dose alternative in palliative care settings, fluconazole 150 mg as a single dose achieved >50% improvement in 96.5% of patients with advanced cancer, though this is not standard guideline-based therapy 3

Topical Therapy (Alternative for Mild Cases)

• Clotrimazole troches 10 mg dissolved slowly in mouth 5 times daily for 7-14 days is effective for initial episodes 1, 4
• Nystatin suspension 200,000-400,000 units swished and swallowed 4 times daily for 7-14 days 1
• Miconazole mucoadhesive tablets 50 mg applied once daily to upper gum 1
• Topical agents maintain salivary concentrations above minimum inhibitory levels for most Candida species when dosed at 3-hour intervals 4

When Topical Therapy is Reasonable

• Use topical agents for initial, mild episodes in immunocompetent patients who prefer to avoid systemic medication 1
• However, recognize that oral fluconazole is more convenient, better tolerated, and associated with superior compliance 2

Refractory or Fluconazole-Resistant Disease

Second-Line Systemic Options

• Itraconazole oral solution 200 mg once daily for 7-14 days 1
• Voriconazole 200 mg (3 mg/kg) orally twice daily for 7-14 days 1
• Posaconazole oral suspension 400 mg twice daily OR extended-release tablets 300 mg once daily 1

Parenteral Therapy (For Severe Cases or Inability to Tolerate Oral Therapy)

• Echinocandins are highly effective alternatives:
  • Caspofungin: 70 mg loading dose, then 50 mg daily 1
  • Micafungin: 100 mg daily 1
  • Anidulafungin: 200 mg loading dose, then 100 mg daily 1
• Amphotericin B deoxycholate 0.3 mg/kg daily is a less preferred alternative due to toxicity 1

Special Populations

HIV-Infected Patients

• Antiretroviral therapy (ART) is essential adjunctive treatment and dramatically reduces the incidence of oropharyngeal candidiasis 1
• For recurrent infections despite treatment, chronic suppressive therapy with fluconazole 100-200 mg three times weekly is recommended 1
• The advent of effective ART has led to marked reductions in both prevalence and refractory disease 1

Immunocompromised Patients with Chronic Mucocutaneous Candidiasis

• Fluconazole is initial therapy, but most patients require chronic suppressive antifungal therapy due to intrinsic immunodeficiency 1
• Development of fluconazole-refractory infections is common in this population 1
• Treat refractory cases similarly to AIDS patients with azole-resistant disease using second-line agents 1

Critical Clinical Considerations

Treatment Duration and Monitoring

• Standard treatment duration is 7-14 days for uncomplicated cases 1
• Most patients experience improvement or resolution within 7 days of initiating antifungal therapy 1
• For patients on prolonged azole therapy (>21 days), periodic monitoring of liver chemistry studies should be considered 1

Common Pitfalls to Avoid

• Do not use ketoconazole or itraconazole capsules as they have variable absorption and are less effective than fluconazole 1
• Echinocandins have higher relapse rates compared to fluconazole, so reserve them for refractory cases or when oral therapy cannot be tolerated 1
• Recognize that esophageal involvement requires systemic therapy—if dysphagia or odynophagia is present, a diagnostic trial of fluconazole 200-400 mg daily for 14-21 days is appropriate before endoscopy 1

When to Suspect Treatment Failure

• Consider non-compliance, inadequate drug absorption, resistant organisms (particularly C. glabrata or C. krusei), or reinfection if treatment fails 5
• Persistent symptoms beyond 7 days warrant reassessment and possible culture with susceptibility testing 1
• Treatment-resistant thrush in otherwise healthy individuals should prompt evaluation for underlying immunodeficiency, including HIV testing and assessment for rare conditions 6, 7