What is Fluconazole used for?

Fluconazole Uses in Clinical Practice

Fluconazole is primarily used to treat various types of Candida infections, including vaginal candidiasis, oropharyngeal and esophageal candidiasis, urinary tract infections, and systemic candidiasis, as well as cryptococcal meningitis. 1

Primary Indications

• Vaginal candidiasis: A single 150mg oral dose provides clinical cure rates of 84-92% for uncomplicated vaginal yeast infections 2, 3
• Oropharyngeal candidiasis: Typically treated with 100-200mg daily for 7-14 days, with clinical cure rates around 90% 2, 4
• Esophageal candidiasis: Requires 200-400mg daily for 14-21 days until clinical improvement is seen 4
• Urinary tract candidiasis:
  • Symptomatic cystitis: 200mg daily for 14 days 4
  • Pyelonephritis: 200-400mg daily for 14 days 4
• Cryptococcal meningitis: Used for both initial treatment and long-term suppressive therapy 1, 5
• Systemic candidiasis: Including candidemia, disseminated candidiasis, and pneumonia 1

Treatment of Specific Candida Infections

Mucosal Candidiasis

• Oropharyngeal candidiasis:

  • First-line: Fluconazole 100-200mg daily for 7-14 days 4
  • For fluconazole-refractory cases: Consider itraconazole solution, voriconazole, or echinocandins 4
  • In HIV-infected patients, recurrent infections are common and may require long-term suppressive therapy 4

• Esophageal candidiasis:

  • Fluconazole 200-400mg daily for 14-21 days 4
  • A therapeutic trial with fluconazole is cost-effective for presumed esophageal candidiasis, with most patients showing symptom resolution within 7 days 4
  • For fluconazole-refractory cases: itraconazole solution (80% response rate) or echinocandins 4

Invasive Candidiasis

• Candidemia: Treatment duration should be at least 2 weeks after the first negative blood culture and resolution of symptoms 4
• CNS candidiasis:
  • Fluconazole 400-800mg (6-12mg/kg) daily for patients unable to tolerate amphotericin B 4
  • Treatment should continue until all signs, symptoms, CSF abnormalities, and radiologic abnormalities have resolved 4
• Candida endophthalmitis:
  • Fluconazole is one treatment option, with therapy lasting at least 4-6 weeks 4
  • Duration determined by repeated examinations to verify resolution 4

Prophylactic Use

• Bone marrow transplantation: Fluconazole is indicated to decrease the incidence of candidiasis in patients undergoing bone marrow transplantation who receive cytotoxic chemotherapy and/or radiation therapy 1
• Solid-organ transplant recipients: Fluconazole 200-400mg daily for at least 7-14 days is recommended as postoperative prophylaxis for high-risk liver, pancreas, and small bowel transplant recipients 4
• ICU patients: Fluconazole 400mg daily is recommended for high-risk patients in adult ICUs with a high incidence of invasive candidiasis 4
• Neutropenic patients: Fluconazole 400mg daily during induction chemotherapy for the duration of neutropenia 4

Dosing Considerations

• Standard dosing:
  • For most indications: 100-400mg daily depending on infection severity 2, 6
  • Loading dose of 800mg (12mg/kg) followed by 400mg (6mg/kg) daily is often used for invasive candidiasis 4
• Renal adjustment: Dose reduction needed in patients with creatinine clearance <50 mL/minute 4
• CNS penetration: Fluconazole achieves excellent levels in CSF (>70% of serum concentrations), making it suitable for CNS infections 4
• Urinary tract: Achieves urine concentrations 10-20 times higher than serum, making it ideal for urinary tract infections 4

Clinical Pearls and Caveats

• Recurrent infections: In immunocompromised patients, especially those with AIDS, recurrent infections are common, and long-term suppressive therapy with fluconazole is often necessary 4
• Drug interactions: Fluconazole inhibits cytochrome P450 enzymes, requiring careful consideration of a patient's drug regimen when adding or removing fluconazole 4
• Resistance concerns: Development of fluconazole-refractory infections is common in chronic suppressive therapy, particularly in patients with chronic mucocutaneous candidiasis 4
• Species-specific considerations: Fluconazole has less activity against C. glabrata and C. krusei than against other Candida species 4

Pharmacokinetic Advantages

• Excellent oral bioavailability (>90%) 2
• Long half-life (22-32 hours) allowing once-daily dosing 6
• Good tissue penetration, including CSF 5
• Primarily excreted unchanged in urine 2