What alternatives are available for a 23-month-old male with recurrent oral thrush (candidiasis) who has completed two courses of nystatin (antifungal medication)?

From the Guidelines

For a 23-month-old with recurrent oral thrush after two courses of nystatin, I recommend fluconazole oral suspension at a dose of 6 mg/kg on the first day, followed by 3 mg/kg once daily for 14 days. This medication is easier to administer than nystatin since it requires only once-daily dosing rather than multiple applications throughout the day. Fluconazole works systemically, which may be more effective for persistent cases that haven't responded adequately to topical nystatin 1. While treating the child, it's essential to also examine potential sources of reinfection, such as pacifiers, bottles, or toys that should be thoroughly cleaned or replaced. If the child is taking antibiotics, this could be contributing to the recurrent thrush by disrupting normal oral flora. For immediate symptom relief, you can apply a small amount of plain yogurt with live cultures to the affected areas of the tongue. If fluconazole doesn't resolve the condition, further evaluation may be needed to rule out underlying conditions affecting immune function or to consider alternative diagnoses such as geographic tongue, which can sometimes be mistaken for thrush.

Some key points to consider in the management of this patient include:

• The importance of proper hygiene and cleaning of items that come into contact with the child's mouth to prevent reinfection 1.
• The potential for antibiotic use to contribute to recurrent thrush and the need to weigh the benefits and risks of antibiotic therapy in this context 1.
• The availability of alternative treatments, such as itraconazole solution, for cases that do not respond to fluconazole 1.
• The need for careful monitoring and follow-up to ensure that the infection is fully cleared and to address any potential complications or underlying conditions that may be contributing to the recurrent thrush 1.

Given the most recent and highest quality evidence, fluconazole oral suspension is the recommended treatment for this patient 1. It is crucial to follow the recommended dosage and treatment duration to ensure effective treatment and minimize the risk of complications or recurrence.

From the Research

Treatment Options for Oral Candidiasis

The patient's symptoms of reoccurring thrush on the tongue can be treated with various antifungal medications. Some options include:

• Nystatin, which is commonly used to treat oral candidiasis, but may require a long time to eradicate the infection 2
• Miconazole, which is also effective but may interact with other drugs 2
• Fluconazole, which can be used to treat oral candidiasis that does not respond to topical treatment 2, 3

Alternatives to Nystatin

Since the patient has already completed two courses of nystatin and the thrush has reoccurred, alternative treatments may be considered. These include:

• Clotrimazole, which has been shown to be effective in treating vaginal candidiasis and may also be used to treat oral candidiasis 4, 5
• Itraconazole, which has been shown to be effective in treating acute vaginal candidiasis and may also be used to treat oral candidiasis 5
• Other systemic treatment alternatives, such as posaconazole or echinocandins, which may be used to treat recalcitrant infections 2, 4

Considerations for Treatment

When choosing a treatment option, it is essential to consider the patient's symptoms, medical history, and potential interactions with other medications. The patient's decreased appetite and difficulty keeping the medication in their mouth should also be taken into account when selecting a treatment option.