Treatment for Chronic Thrush Infection

Initial Treatment Based on Severity

• The Infectious Diseases Society of America recommends topical antifungal agents as first-line therapy for mild oropharyngeal candidiasis, including clotrimazole troches, 10 mg 5 times daily for 7-14 days, miconazole mucoadhesive buccal 50-mg tablet applied once daily for 7-14 days, or nystatin suspension (100,000 U/mL) 4-6 mL 4 times daily, for 7-14 days 1, 3, 4
• For moderate to severe disease, the Infectious Diseases Society of America recommends oral fluconazole, 100-200 mg daily, for 7-14 days 1, 3

Management of Fluconazole-Refractory Disease

• The Infectious Diseases Society of America recommends itraconazole solution, 200 mg once daily, or posaconazole suspension, 400 mg twice daily for 3 days then 400 mg daily, for up to 28 days, as alternative treatments for fluconazole-refractory disease 4, 5
• For severe refractory cases, the Infectious Diseases Society of America recommends intravenous echinocandin (caspofungin: 70-mg loading dose, then 50 mg daily; micafungin: 100 mg daily; or anidulafungin: 200-mg loading dose, then 100 mg daily) or intravenous amphotericin B deoxycholate, 0.3 mg/kg daily 4, 6

Chronic Suppressive Therapy

• The Infectious Diseases Society of America recommends fluconazole, 100 mg 3 times weekly, for chronic suppression in patients with recurrent infection 1, 6, 7

Special Considerations

• The Infectious Diseases Society of America strongly recommends antiretroviral therapy to reduce the incidence of recurrent infections in HIV-infected patients 7, 8
• The Infectious Diseases Society of America recommends disinfection of the denture, in addition to antifungal therapy, as essential for successful treatment of denture-related candidiasis 6, 7

Monitoring and Follow-up

• The Infectious Diseases Society of America recommends monitoring for clinical improvement within 48-72 hours of initiating therapy 1

Potential Pitfalls

• The Infectious Diseases Society of America warns against failure to identify and address underlying risk factors, such as immunosuppression, diabetes, broad-spectrum antibiotics, and inhaled corticosteroids, which can lead to recurrent infection 1
• The Infectious Diseases Society of America advises against inadequate treatment duration, which can lead to incomplete eradication and early recurrence 1, 4
• The Infectious Diseases Society of America recommends considering fluconazole-resistant Candida species (C. glabrata, C. krusei) in refractory cases 4
• The Infectious Diseases Society of America emphasizes the importance of denture hygiene in denture wearers to prevent reinfection 7