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Note that oral candidiasis is uncommon in immunocompetent adults and therefore the evidence is taken from randomised controlled trials in children and immunocompromised adults. However anti-fungals are likely to be more effective in the immunocompetent adult population. Also note that as oral candidiasis is uncommon in immunocompetent adults, consider investigating for an underlying comorbidity or immunosuppressive illness.

1
Hoppe J, Treatment of oropharyngeal candidiasis in immunocompetent infants: A randomized multicentre study of Miconazole gel vs Nystatin suspension, Antifungals study group, Pediatr Infect Dis J. 1997 Mar;16(3):288-93. 227 patients under the age of 1 year were recruited to the trial. Cure by day 5 was achieved by 84.7% of 98 patients in the miconazole treatment arm compared with 21.2% of 85 treated with nystatin. At day 8 the cure rates were 96.9% versus 37.6% and at day 12 they were 99.0% versus 54.1%. There was not a statistically significant increase of side-effects (4.5% Miconazole / 3.5 Nystatin) or relapse rates with Miconazole.

2
Hoppe J, Hahn H, Randomized comparison of two nystatin oral gels with miconazole oral gel for treatment of oral thrush in infants. Antimycotics Study Group, Infection 1996, 24(2) 2136-139. 95 otherwise healthy patients under the age of one year were recruited to this trial. Clinical cure in Miconazole study group 85.1% (27 patients) compared with 42 and 28% in branded nystatin groups (33 and 35 patients). Relapses were seen in nystatin groups (15 patients) but not in miconazole group.

3
Bensadoun R, Daoud J et al, Comparison of the efficacy and safety of miconazole 50-mg mucoadhesive buccal tablets with miconazole 500-mg gel in the treatment of oropharyngeal candidiasis. A prospective, randomized, single-blind, multicenter, comparative, phase III trial in patients treated with radiotherapy for head and neck cancer, Cancer. 2008 Jan 1;112(1):204-11. In this comparative trial of cancer patients oral candidiasis was effectively treated by both tablet and gel formulations. Clinical success was achieved in 56% of 141 patients who received 14 days of buccal tablet administration miconazole and 49% of 141 patients who received 14 days of the gel preparation. Other end-points of this study were largely non-significant but 29% of patients who used buccal preparation had side-effects versus 27% in the gel preparation group. However fewer people dropped out of study due to serious adverse events (3 versus 6 respectively) when using the buccal preparation.

4
Pons V, Greenspan D, et al. Oropharyngeal candidiasis in patients with AIDS: randomized comparison of fluconazole versus nystatin oral suspensions. Clin Infect Dis. 1997;24(6):1204-1207. Cure was achieved at day 14 in 87% of 83 HIV positive patients who were treated with fluconazole and 52% of 84 patients who received nystatin. Mycological clearance was achieved in 60% of the fluconazole arm and 6% of patients treated with nystatin; 18% of patients relapsed on fluconazole contrasted with 44% on nystatin respectively at day 28. GI side effects were comparable but two patients in the fluconazole arm developed deranged LFTs, one having to withdraw.

5
Flynn PM, Cunningham CK et al, Oropharyngeal candidiasis in immunocompromised children: a randomized, multicenter study of orally administered fluconazole suspension versus nystatin. The Multicenter Fluconazole Study Group. J Pediatr. 1995 Aug;127(2):322-8. 91% of patients treated with fluconazole were cured at day 14 compared with 51% of patients treated with nystatin. Mycologically there was organism eradication in 76% on fluconazole versus 11% on nystatin. Both regimens were tolerated well with similar relapse rates.

6
BHIVA British HIV Association and British Infection Association Guidelines for the Treatment of Opportunistic Infection in HIV-seropositive Individuals 2011 http://www.bhiva.org/documents/Guidelines/OI/hiv_v12_is2_Iss2Press_Text.pdf (Accessed 13.11.14). This recommends fluconazole treatment for oral candidiasis in HIV positive patients. Patients with extensive/severe candidiasis or with a background of HIV should receive oral fluconazole therapy. If patients are systemically unwell or have not responded to oral fluconazole consider referral to secondary care.

7
Clinical Knowledge Summaries, Oral Candidiasis, Revised July 2013, http://cks.nice.org.uk/candida-oral (Accessed 19.11.14). A majority of patients will respond to a one-week course of topical antifungal therapy and patients should continue to use the treatment for a further 2 days following resolution of symptoms. Those patients who get some relief but have persisting symptoms should continue to complete a two-week course.

The POCAST project is funded by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London and by the Imperial College Healthcare Charity (Grant Ref No:7006/P36U).