What is the treatment for thrush?

Treatment for Thrush (Oropharyngeal Candidiasis)

For mild oropharyngeal thrush, start with clotrimazole troches 10 mg five times daily for 7-14 days, or alternatively use miconazole mucoadhesive buccal 50-mg tablet once daily; for moderate to severe disease, use oral fluconazole 100-200 mg daily for 7-14 days. 1

Treatment Algorithm by Disease Severity

Mild Disease (First-Line Options)

• Clotrimazole troches 10 mg five times daily for 7-14 days is the preferred topical therapy 1, 2
• Miconazole mucoadhesive buccal 50-mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days is equally effective 1, 2
• Nystatin suspension (100,000 U/mL) 4-6 mL four times daily for 7-14 days is an alternative 1, 2
• Nystatin pastilles (200,000 U each) 1-2 pastilles four times daily for 7-14 days 1, 2

Moderate to Severe Disease

• Oral fluconazole 100-200 mg daily for 7-14 days is the recommended systemic therapy 1, 2
• This is preferred over topical options when disease is more extensive 1

Fluconazole-Refractory Disease

When patients fail initial fluconazole therapy, escalate to:

• Itraconazole solution 200 mg once daily for up to 28 days 1, 2
• 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 1, 2
• Amphotericin B deoxycholate oral suspension 100 mg/mL four times daily 1, 2
• IV 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
• IV amphotericin B deoxycholate 0.3 mg/kg daily 1

Important Clinical Considerations

Treatment Duration

• Continue therapy for 7-14 days for uncomplicated disease 1, 2
• Treatment should continue until clinical resolution of symptoms 2
• Cure rates with topical antifungals are approximately 80-90% when the full course is completed 2

Chronic Suppressive Therapy

• Chronic suppressive therapy is usually unnecessary 1
• If required for recurrent infections: fluconazole 100 mg three times weekly 1, 2

Special Populations

• HIV-infected patients should receive antiretroviral therapy in addition to antifungal treatment 1
• Neonates: Use amphotericin B deoxycholate 1 mg/kg daily OR fluconazole 12 mg/kg daily for at least 3 weeks 1

Denture-Related Candidiasis

• Disinfection of dentures is essential in addition to antifungal therapy when thrush is denture-related 2

Common Pitfalls to Avoid

Do not confuse oropharyngeal thrush with esophageal candidiasis, which requires higher fluconazole doses (200-400 mg daily) and longer treatment duration (14-21 days) 1

Avoid premature discontinuation of therapy - patients must complete the full 7-14 day course even if symptoms improve earlier to prevent recurrence 1, 2

Do not use systemic antifungals for simple Candida colonization of respiratory secretions without evidence of true infection 1

Evidence Quality Note

The 2016 IDSA guidelines provide the most current recommendations, with strong evidence (high-quality) supporting both topical clotrimazole/miconazole and oral fluconazole for appropriate disease severity 1. The topical agents have moderate-to-high quality evidence, while fluconazole for moderate-to-severe disease has high-quality evidence supporting its use 1.