eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Thrush: Treatment & Medication
Updated: Jan 23, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Although some anecdotal reports indicate no treatment is necessary for otherwise healthy neonates, no published studies support this assertion.5
Consultations
In cases in which underlying immune dysfunction is suspected, consultation with an immunologist and infectious diseases specialist may be warranted for further evaluation.
Diet
No special diet is indicated.
Medication
Antifungal therapy generally hastens resolution of infection. The treatment of choice for thrush is oral nystatin suspension, although numerous antifungal agents are effective. Resistance to nystatin is rare, although the drug's contact killing makes it somewhat more difficult to use because it must be applied to all of the affected mucosal surfaces to be effective (unlike systemic therapies).
In older children and adults, antifungal medications should be swished around in the oral cavity and swallowed. Failure to do so may provide ineffective treatment for lesions in the posterior pharynx and esophagus. In younger patients, instruct parents to apply 1-2 mL of the solution to the inside of each cheek during each administration. Medication can also be directly applied to the lesions with a nonabsorbent swab or applicator. The best time to administer medication is between meals because this allows longer contact time.
Gentian violet solution should not be swallowed. Lozenges (troches) may be used if suspension preparations are unavailable.
These antifungal preparations have minimal adverse effects and few contraindications because they involve little or no systemic absorption. Aside from itraconazole, against which candidal resistance is increasing, other readily available antifungals are effective. If inability to adequately apply nystatin (or the oral cavity's normal flushing mechanisms) results in treatment failure, oral fluconazole or gentian violet are second-line agents.
Antifungal agents
The mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal cell.
Nystatin (Mycostatin, Nilstat, Nystex)
DOC for oral thrush. No significant absorption from the intact skin, GI tract, or vagina. Fungicidal and fungistatic antibiotic obtained from Streptomyces noursei; effective against various yeasts and yeastlike fungi. Changes permeability of fungal cell membrane after binding to cell membrane sterols, causing cellular contents to leak.
Adult
400,000-600,000 U PO; swish and swallow 4-5 times/d
Dissolve 1-2 (200,000-400,000 U) troches (lozenges) in mouth 4-5 times/d
Continue treatment until 48 h after symptoms disappear
Pediatric
Infants, young children: Apply 100,000-200,000 U PO susp to affected areas of mouth 3-5 times/d
Continue treatment until 48 h after symptoms disappear
Older children: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
No serious adverse effects; bitter taste, nausea, abdominal pain, diarrhea, urticaria
Amphotericin B (Fungizone Oral Suspension)
Produced by a strain of Streptomyces nodosus; can be fungistatic or fungicidal. Binds to sterols (eg, ergosterol) in the fungal cell membrane, causing intracellular components to leak with subsequent fungal cell death.
Adult
100-200 mg PO; swish and swallow qid
Pediatric
Apply 100-mg oral susp to affected areas of mouth qid
Unlikely with PO administration because of poor absorption; may increase nephrotoxicity when used with aminoglycosides and possibly with cephalosporins; may increase methotrexate toxicity; increases curariform effect of curariform drugs
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Minimal adverse effects expected with PO administration
Clotrimazole (Mycelex Troches)
Alters cell membrane. Very effective treatment in immunocompetent host. If susp not available (not available in the United States), troches (lozenges) can be used, but troche has been associated with elevated liver enzymes and GI adverse effects.
Adult
10 mg troche dissolved PO 5 times/d
Pediatric
Infants: Not established
Older children: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Not for treatment of systemic fungal infections; avoid contact with the eyes; if irritation or sensitivity develops, discontinue use and institute appropriate therapy
Miconazole oral gel (Daktar)
Not available in the United States. Damages fungal cell wall membrane by inhibiting biosynthesis of ergosterol; increases membrane permeability, causing nutrients to leak out, resulting in fungal cell death.
Adult
Pediatric
Apply 25 mg to affected areas of mouth qid; exact PO topical dose not established
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Sensitivity or chemical irritation
Gentian violet
Although inexpensive, efficacious for thrush refractory to other therapies. Solution stains clothing and mucosa intensely, causing undesirable cosmetic effects.
Adult
2% solution PO topically bid; treat until plaques clear
Pediatric
Infants: 3-4 gtt 0.5% solution PO topically qd pc
Children: 1% solution PO topically qd; treat until plaques clear
None reported
Documented hypersensitivity; ulcerated areas; porphyria
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Esophagitis if swallowed; may burn skin; intense staining of mucosa may interfere with assessment of response
Fluconazole (Diflucan)
Azole antifungal with excellent bioavailability. Interferes with cell membrane and is eliminated via renal pathway.
Fungistatic activity. Synthetic PO antifungal (broad-spectrum bistriazole) that selectively inhibits fungal CYP450 and sterol C-14 alpha-demethylation, which prevents conversion of lanosterol to ergosterol, thereby disrupting cellular membranes.
Adult
200 mg PO qd on day 1; followed by 100 mg/d PO for 3-4 d; total of 5 d should be adequate
Pediatric
6 mg/kg/d PO qd
Serum levels may increase with hydrochlorothiazide; levels may decrease with chronic coadministration of rifampin; coadministration may decrease phenytoin clearance; may increase concentrations of theophylline, tolbutamide, glyburide, and glipizide; effects of anticoagulants may increase with coadministration; cyclosporine concentrations increases may occur when administered concurrently
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor closely if rash develops and discontinue drug if lesions progress; may cause clinical hepatitis, cholestasis, and fulminant hepatic failure (including death), with underlying medical conditions (eg, AIDS, malignancy) and while taking multiple concomitant medications; not recommended for nursing mothers
More on Thrush |
| Overview: Thrush |
| Differential Diagnoses & Workup: Thrush |
 Treatment & Medication: Thrush |
| Follow-up: Thrush |
| References |
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Further Reading
Keywords
thrush, Candida albicans, C albicans, candidal diaper rash, candidiasis, diaper dermatitis, fungal infection, hepatosplenomegaly, human immunodeficiency virus, HIV, immune dysfunction, lymphadenopathy, monilia, moniliasis, mucocutaneous candidiasis, oral candidiasis, oral thrush, oropharyngeal yeast infection, polyendocrine disorders, vaginal candidiasis, white tongue coating
