Fast Fact and Concept #147: Oropharyngeal Candidiasis

Author: Drew A Rosielle, MD

Oropharyngeal candidiasis (thrush) occurs commonly in seriously ill and dying patients.

RISK FACTORS: a) defects of cell-mediated immunity: acquired (HIV-AIDS) or drug-induced (chemotherapy, inhaled or systemic glucocorticoids); b) disruption of the oropharyngeal mucosa by cytotoxic chemotherapy (See Fast Fact # 121-Mucositis) or irradiation that includes the oropharynx; c) xerostomia (dry mouth) from any cause; d) diabetes mellitus; e) recent antibiotic use; f) dentures; and g) advanced age.

DIAGNOSIS: Thrush is often asymptomatic but can lead to oral pain, oropharyngeal dysphagia, halitosis, alterations in taste, diminished appetite, and reduced oral intake. Thrush may or may not be present in cases of esophageal candidiasis which presents as odynophagia and esophageal dysphagia. Most cases of thrush are caused by Candida albicans; C. krusei, glabrata, or tropicalis are sometimes implicated in AIDS and cancer patients. Diagnosis is made on clinical findings: white, cottage-cheese like plaques on the buccal mucosa, tongue or palate. The plaques are easily removed, leaving a red or bleeding and often painful base. A less common presentation--seen in AIDS or in patients with poorly fitting dentures--involves red, edematous, and sometimes eroded mucosal lesions, but without plaques. If diagnostic doubt exists, confirmation can be made by KOH staining a wet-prep of a plaque scraping, revealing pseudohyphal Candidal forms. Culture is not recommended as Candida species are common colonizers of the mouth.

TREATMENT: The decision to treat thrush should be based on the patient's overall condition, prognosis, symptoms, and goals of care. Treatments include either systemic or topical anti-fungal drugs. All regimens should be continued for 10-14 days. Meticulous attention to denture cleaning, if applicable, is important to prevent recurrence. If esophageal candidiasis is suspected, systemic therapy is necessary as topical treatment is ineffective.

Topical drugs are the most commonly used but problems can occur due to patient objections to taste and compliance with multiple daily dosing.

• Nystatin suspension (“swish and swallow”) is dosed as 200,000-400,000 Units 4 - 5 times a day. It is substantially less effective in immunocompromised patients than the azole anti-fungals (30-50% vs 70-90% effective) and should not be used in this population.
• Clotrimazole (10 mg troches 5 times a day) is nearly as effective as the systemic azole anti-fungals, however, it is associated with a higher recurrence rate of thrush.

Systemic drugs are more effective than the topicals. However they are more expensive and have significant drug-drug interactions— especially with macrolide antibiotics, anticonvulsants, benzodiazepines, methadone, and coumadin.

• Fluconazole is the systemic treatment of choice; it is more effective with fewer drug interactions than ketoconazole. Many dosing regimens have been described: 200mg once, then 100mg daily for 13 days is most commonly used.
• Itraconazole suspension (200mg daily) is an alternative to fluconazole. It is better absorbed and more effective than itraconazole capsules.

Note: Fluconazole resistant candidiasis is rare, but becoming more common. Itraconazole, IV or oral amphotericin, voriconazole, and caspofungin have all been used with success.

RECOMMENDATIONS: Clotrimazole troches are a reasonable first line therapy for patients in the palliative care setting if the troches are tolerable and 5 times a day dosing is acceptable. If not, and/or if the patient has problems with recurrent thrush, fluconazole should be used.

References

1. Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis 2004; 38:161-89.
2. Patton LL, Bonite AJ, Shugars DA. A systematic review of the effectiveness of antifungal drugs for the prevention and treatment of oropharyngeal candidiasis in HIV-positive patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 92:170-179.
3. Powderly WG, Mayer KH, Perfect JR. Diagnosis and treatment of oropharyngeal candidiasis in patients infected with HIV: a critical reassessment. AIDS Res & Human Retrovir 1999; 15(16):1405-1412.
4. Shay K, Truhlar M, Renner RP. Oropharyngeal candidosis in the older patient. J Am Geri Soc 1997; 45(7):863-870.
5. Soysa , NS , Samaranayake LP, Ellepola ANB. Cytotoxic drugs, radiotherapy and oral candidiasis. Oral Oncol 2004; 40:971-978.
6. Sweeney MP, Bagg J. The mouth and palliative care. Am J Hosp & Pall Care 2000; 17(2):118-124.

Copyright/Referencing Information: Users are free to d ownload and distribute Fast Facts for educational purposes only. Citation for referencing: Rosielle D. Fast Facts and Concepts #147; Oropharyngeal Candidiasis. December, 2005. End-of-Life/Palliative Education Resource Center www.eperc.mcw.edu.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

 Purpose: Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge and Patient Care

Keyword(s): Non pain symptoms and syndromes