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Clinician’s Corner: Thrush

Lets talk about another member of the fungus family, Candida albicans, which is more specifically a yeast. Our first mucus membrane we will cover is the mouth.  Candida albicans infection of the mouth is commonly referred to as “thrush”.  Candida albicans is a yeast of our normal microbes on our mucus membranes, that is kept “in check” by a variety of bacteria especially Lactobacillus .  When the immune system is weakened, or the bacteria are wiped out by antibiotics, Candida albicans can overgrow.

Symptoms: Thrush is most often seen as white patches on the inner cheeks, tongue, roof of the mouth, and throat. Other symptoms might include: redness or soreness, feeling like cotton in the mouth and loss of taste. Patients may also experience pain while eating or swallowing and cracking and redness at corners of the mouth.

Who is at risk:

Thrush is uncommon in healthy adults. People who are at higher risk for getting candidiasis in the mouth and throat include babies, especially those younger than one-month old, and people who:

  • Wear dentures
  • Have diabetes
  • Have cancer
  • Have HIV/AIDS: thrush is one of the most common infections seen in the AIDS population.
  • Take antibiotics or corticosteroids, including inhaled corticosteroids for conditions like asthma
  • Take medications that cause dry mouth or have medical conditions that cause dry mouth
  • Smoke

Treatment of Adults:

The treatment of oropharyngeal candidiasis in patients without AIDS is usually accomplished with local therapy for 7 to 14 days. For topical agents, successful therapy depends on adequate contact time between the agent and the oral mucosa. Options include:

  • Clotrimazole troches or lozenges are dosed at 10mg 5 times a day slowly dissolved in the mouth for about 15-30 minutes. Patients who don’t produce adequate saliva might have difficulty getting these lozenges to dissolve.  Don’t eat or drink while using.
  • Nystatin suspension 100,000 units/ml swish and swallow 4-6 ml four times daily is effective but has a bitter taste. It also contains sucrose, which can cause dental caries when used over prolonged time periods.
  • Fluconazole tablets: 200mg first dose then follow with 100mg-200mg daily.  Best option for topical treatment failures.  Has 90% success rate.

Children Doses for Candida albicans eradication:

Nystatin Oral suspension 100,000 units/ml:

  • For older infants: 2 mL four times a day.
  • For premature and low-birth-weight infants: 1 mL four times a day.
  • The suspension should be retained in the mouth for as long as possible before swallowing to improve contact time for a better cure rate.
  • Infants should avoid feeding for 5 to 10 minutes after administration to keep nystatin from washing out of the mouth.

Fluconazole:        available as 10mg/ml and 40mg/ml in 35ml bottles for reconstitution

  • Dose: 6 mg/kg orally once on the first day (maximum dose 200 mg), followed by 3 mg/kg once per day (maximum dose 100 mg) for a total of 7 to 14 days. Doses are higher for HIV infection.

Prevention of reinfection in babies

  • sterilize items that are placed in the infant’s mouth. Bottle nipples and pacifiers that are to be reused should be boiled after each use.
  • Breast feeding: Topical miconazole or clotrimazole is applied to the nipples to treat the lactating woman. Wipe off prior to feeding and reapply after each feeding.