Treatment for Oral Thrush
For mild oral thrush, start with topical clotrimazole troches 10 mg five times daily or miconazole mucoadhesive buccal tablets 50 mg once daily for 7-14 days; for moderate to severe disease, use oral fluconazole 100-200 mg daily for 7-14 days. 1
Disease Severity-Based Treatment Algorithm
Mild Disease (First-Line Options)
- Clotrimazole troches 10 mg five times daily for 7-14 days 1
- Miconazole mucoadhesive buccal tablet 50 mg applied to the mucosal surface over the canine fossa once daily for 7-14 days 1
- These topical agents carry strong recommendations with high-quality evidence from the IDSA 1
Mild Disease (Alternative Topical Options)
- Nystatin suspension (100,000 U/mL) 4-6 mL four times daily for 7-14 days 1
- Nystatin pastilles (200,000 U each) 1-2 pastilles four times daily for 7-14 days 1
- While nystatin is effective, it requires more frequent dosing and has lower patient acceptance due to taste issues 2, 3
Moderate to Severe Disease
- Oral fluconazole 100-200 mg daily for 7-14 days is the treatment of choice 1, 4
- This recommendation carries strong evidence with high-quality data 1
- Fluconazole demonstrates superior mycologic cure rates (49%) compared to topical agents like clotrimazole (27%) 5
Refractory Disease Management
Fluconazole-Refractory Thrush (First-Line)
- Itraconazole solution 200 mg once daily for up to 28 days 1, 4
- Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 1, 4
Fluconazole-Refractory Thrush (Alternatives)
- Voriconazole 200 mg twice daily 1, 4
- Amphotericin B deoxycholate oral suspension 100 mg/mL four times daily 1
- For severe refractory cases requiring parenteral therapy: intravenous echinocandins (caspofungin 70 mg loading dose then 50 mg daily, micafungin 100 mg daily, or anidulafungin 200 mg loading dose then 100 mg daily) 1
Special Considerations and Clinical Pitfalls
Denture-Related Candidiasis
- Denture disinfection is mandatory in addition to antifungal therapy 1, 4
- Failure to disinfect dentures leads to treatment failure and rapid recurrence 1
Recurrent Thrush
- Chronic suppressive therapy with fluconazole 100 mg three times weekly is recommended for patients with recurrent infections 1, 4
- This approach is usually unnecessary but indicated when recurrences are frequent 1
HIV-Infected Patients
- Antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections 1, 4
- Fluconazole resistance develops most commonly in patients with CD4 counts <200 cells/μL who receive prolonged fluconazole prophylaxis 5
- Resistance can occur through acquisition of new resistant strains or development of resistance in previously susceptible strains 5
Resistance Patterns
- Monitor for fluconazole resistance, particularly with minimum inhibitory concentrations ≥64 μg/mL, which correlates with clinical failure 5
- Cross-resistance between fluconazole and itraconazole occurs in approximately 30% of fluconazole-resistant isolates 1
- Non-albicans species like Torulopsis glabrata may increase after treatment but rarely cause thrush as sole pathogens 5
Drug Interactions
- Miconazole has significant drug-drug interactions that must be assessed before prescribing 2
- Itraconazole and voriconazole have more potential drug interactions compared to fluconazole 1
Agents to Avoid
- Ketoconazole should not be used due to hepatotoxicity and drug interactions 1
- Topical amphotericin B and nystatin are suboptimal for initial therapy due to poor tolerability, bitter taste, and frequent dosing requirements 1
- Echinocandins should not be used for triazole-susceptible disease due to parenteral-only availability and cost 1