Oropharyngeal candidiasis

Background

  • Typically occurs when the normal host immunity or host flora are disrupted, allowing for overgrowth of Candida albicans
  • Most commonly seen in infants, immunocompromised, older adults with dentures

Risk Factors

  • Extremes of age
  • Antibiotics
  • Corticosteroids
  • Immunocompromised (AIDS, immunosuppressant medications)

Clinical Features

  • White curd-like (pseudomembraneus) plaques that are difficult to remove and leave behind an erythematous base on the oral mucosa, tongue, palate, or oropharynx
  • Usually painless
  • Cotton sensation in mouth
  • Angular cheilitis
  • Loss of taste

Differential Diagnosis

Tongue diagnoses

Oral rashes and lesions

Evaluation

  • Most cases are diagnosed clinically and need only one of the treatments listed below[1]
    • May consider KOH prep of skin scrapings (using a tongue depressor), if available
  • Consider HIV testing if no other etiology is determined or if risk factors are present

Management

Treatment is targeted against Candida species

  • Topical agents
    • Patients with their first presentation of mild thrush
  • Azole therapy
    • Patients with moderate to severe oropharyngeal candidiasis or for those
    • Patients with recurrent disease
    • HIV-positive patients who are at risk of developing esophageal candidiasis (CD4 count <100 cells/microL)

Antifungals

  • Voriconazole 200mg BID up to 28 days until symptom resolution
    • only for Candida species resistant to fluconazole
  • Nystatin oral suspension 400,000-600,000 units (swish and swallow) Q6H until 48 hours after symptoms disappear OR
  • Clotrimazole 10 mg troches 5 times/day for 14 consecutive days OR
  • Fluconazole 200 mg (Peds: 6 mg/kg) PO on day one, followed by 100 mg (Peds: 3 mg/kg_ daily for two weeks.
    • Fluconazole is reserved for moderate to severe disease

Pediatric Dosing

If the patient is breast feeding it is important for the mother to treat her nipples before and after feeding

  • Nystatin Oral Suspension
    • 100,000 units/ml for 14 days for all ages
    • Premature infants should only have 0.5 - 1 mL given to each side of the mouth every 6 hours
  • Clotrimazole 10mg PO five times daily for 14 days
    • reserved for patients > 3 years old


Disposition

  • Thrush is typically self-limited and patients may be discharged home unless concomitant symptoms require further work-up

See Also

References

  1. Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1.

Authors:

Ross Donaldson