Fungal Infections

Comments

Clinically candida infections can present as three main variants: pseudomembraneous, erythematous and hyperplastic. Chronic hyperplastic candidosis is potentially pre-malignant and therefore refer patients with this condition for specialist treatment.

N.B. oral candidiasis may be a clinical marker for an underlying pre-disposing condition e.g. diabetes, nutritional deficiencies, immuno-compromise, or may be associated with the use of inhaled corticosteriods, cytotoxics, or broad-spectrum antimicrobials.

Fungal infections in immuno-compromised patients are likely to need intravenous systemic treatment and should be referred.

Treatment with nystatin is effective against superficial infections but compliance is poor because of it’s unpleasant taste, therefore micanazole oral gel or the systemically absorbed drug fluconazole are preferred unless contra-indicated ³.

Note that fluconazole and miconazole interact with many drugs including warfarin and statins and therefore do not prescribe to patients taking these drugs³.


Local Measures

  • Advise patients using corticosteroid inhalers to rinse mouth with water or brush teeth immediately after use.
  • Brush the palate daily.
  • Advise denture wearers re denture hygiene – clean the denture by soaking in chlorhexidine mouthwash or sodium hypochlorite twice daily (note hypochlorite can only be use for acrylic dentures).
  • Leave the dentures out as often as possible during the treatment period 3, 4 
  • Assess adequacy of denture

Treatment

Where anti-fungal treatment is considered necessary:

Treatment Dose TX Duration

Adults

First line Miconazole*
20mg/g oral gel
40g tube

OR
2.5ml to the affected area four times daily – after meals.
Do not swallow immediately, keep in contact with the affected area as long as possible Dental prostheses should be removed at night and brushed with gel
7 days or longer – treatment should be continued for 7 days after the lesions have healed
Fluconazole*
capsules

OR
50mg once daily 7-14 days, maximum 14**
Nystatin
Oral suspension 30ml bottle
1 ml to the affected area four times daily – after meals.
Do not swallow immediately, keep in contact with the affected area as long as possible
7 days or longer – treatment should be continued for 2 days after the lesions have healed

Children

Treatment  Dose TX Duration
First line Miconazole*
20mg/g oral gel

OR
1mth-2 yrs: 1.25ml four times daily smeared round the inside of the mouth after meals
2 yrs – 18 yrs: 2.5 ml four times daily after meals, retain near lesions before swallowing. Orthodontic appliances should be removed at night and brushed with gel
Treatment should be continued for at least 7 days after lesions have healed
Fluconazole* suspension 50mg/5ml, 35ml bottle or capsules

OR
6mths-12 years: 3mg-6mg/Kg on first day, followed by 3 mg/Kg daily up to a max. of 100mg daily

12years-18years: 50mg daily
7-14 days, maximum 14**
Nystatin
Oral suspension
1 ml to the affected area four times daily – after meals.
Do not swallow immediately, keep in contact with the affected area as long as possible
7 days or longer – treatment should be continued for 2 days after the lesions have healed

*Do not prescribe for patients taking Warfarin or Statins³  Check for drug interactions before prescribing
**Non-responders or immuno-compromised patients should be referred (3,4)


Patient Information

Visit HPSC Information Leaflets pages for the General Public, (MRSA, CRE, etc)


Reviewed June 2016

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