Medication Summary
Antifungal therapy generally hastens resolution of infection. [11, 39] The treatment of choice for thrush is fluconazole or 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). Failures with nystatin are more common than with fluconazole. [12]
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
Class Summary
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.
Amphotericin B deoxycholate (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.
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.
Miconazole oral (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.
Gentian violet
Although inexpensive, efficacious for thrush refractory to other therapies. Solution stains clothing and mucosa intensely, causing undesirable cosmetic effects.
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.
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White plaques are present on the buccal mucosa and the undersurface of the tongue and represent thrush. When wiped off, the plaques leave red erosive areas. Courtesy of Matthew C. Lambiase, DO.
