Oral thrush is often over-diagnosed in the immuno-competent. Prescribing is only recommended where symptomatic thrush has been identified. Oral thrush tends to be more problematic in cancer patients, other immune-compromised patients, and those on corticosteroids.

Failure to respond to treatment (particularly in the immuno-compromised) may indicate mouth ulceration due to herpes. The appropriate swab is required.

Continue treatment until 48 hours after the lesions have resolved.

Oral fluconazole may be considered following failure or contraindication to topical treatments and is included in section 5.2.1 Triazole antifungals.

For guidance on the management of oral candidiasis in palliative care see section 16.10 Oropharyngeal problems in palliative care.

Miconazole

• Oromucosal gel sugar free 20mg/g (£4.38 = 80g)

Dose

• Infants: 4-24 months: 1.25ml applied four times. Each dose should be divided into smaller portions and the gel should be applied to the affected area(s) with a clean finger after feeds. The gel should not be applied to the back of the throat due to possible choking. The lower age limit should be increased to 5-6 months of age for infants who are pre-term, or infants exhibiting slow neuromuscular development
• Adults and children 2 years of age and older: 2.5ml applied four times a day after meals. Dental prostheses should be removed at night and brushed with the gel
• The gel should not be swallowed immediately, but retained in the mouth for as long as possible near the lesions
• The treatment should be continued for at least a week after lesions have healed or symptoms have cleared

Notes

1. Stock shortage (14 May 2024): Miconazole 20mg/g oromucosal gel sugar free is unavailable
   1. Anticipated re-supply date is July 2026.
   2. The Specialist Pharmacy Service (SPS) recommends the following:
      1. consider prescribing nystatin 100,000units/ml oral suspension, where appropriate
      2. consider prescribing fluconazole capsules or oral suspension for more severe infections
      3. where the above are not appropriate, advice should be sought from specialists
      4. patient/carers should be advised on the change and counselled on how to administer the dose.
2. Miconazole greatly enhances the anti-coagulation effect of warfarin, avoid concomitant use. Refer also to MHRA Drug Safety Update (June 2016).
3. Refer to the BNF or manufacturer's Summary of Product Characteristics (SPC) for a full list of interactions with miconazole.

Nystatin

• Oral suspension 100,000units/ml (£1.80 = 30ml)

Dose

• 1ml four times daily
• Treatment is usually for 7 days with continuation for at least 48 hours after symptoms have disappeared. If signs and symptoms worsen or persist beyond 14 days of treatment, the patient should be re-evaluated, and alternate therapy considered

Notes

1. It is important that the dose remains in contact with the affected area for as long as possible.
2. Since the absorption of nystatin from the gastro-intestinal tract is negligible, overdose or accidental ingestion causes no systemic toxicity. It is important that the dose remains in contact with the affected area for as long as possible.
3. Dentures must be removed when nystatin is used to ensure all of the mouth is coated. Dentures can be soaked in a sodium hypochlorite solution (e.g. Milton or Dentural) for 20 minutes, rinsed and air-dried.