What is the first line treatment for candidiasis?

First-Line Treatment for Candidiasis

The first-line treatment for candidiasis depends critically on the anatomic site and clinical presentation, but for the most common forms: oral fluconazole 150 mg single dose or topical azoles for vulvovaginal candidiasis, oral fluconazole 100-200 mg daily for oropharyngeal candidiasis, and echinocandins for invasive candidiasis/candidemia in hospitalized patients. 1, 2

Vulvovaginal Candidiasis (Uncomplicated)

For uncomplicated vulvovaginal candidiasis, either topical azole antifungals OR oral fluconazole 150 mg as a single dose are equally effective first-line options. 1, 2

• Topical azoles (clotrimazole, miconazole) applied intravaginally for 1-7 days achieve 92-99% clinical cure rates at short-term evaluation and demonstrate equal efficacy to oral therapy 2, 3
• Oral fluconazole 150 mg single dose provides 92-99% clinical cure rates at short-term evaluation and 88-91% efficacy at long-term follow-up 2
• No single topical agent is superior to another; choice is based on patient preference and convenience 1

Recurrent Vulvovaginal Candidiasis

• Initial treatment with fluconazole 150 mg single dose, followed by maintenance therapy with fluconazole 150 mg weekly for 6 months 2
• Address predisposing factors including uncontrolled diabetes, antibiotic use, immunosuppression, and poor hygiene 2

Oropharyngeal Candidiasis

Treatment selection depends on disease severity:

Mild Disease

• Clotrimazole troches 10 mg 5 times daily for 7-14 days OR miconazole mucoadhesive buccal 50-mg tablet applied once daily for 7-14 days 1
• Alternative: nystatin suspension (100,000 U/mL) 4-6 mL 4 times daily OR nystatin pastilles (200,000 U each) 4 times daily for 7-14 days 1

Moderate to Severe Disease

• Oral fluconazole 100-200 mg daily for 7-14 days 1
• Fluconazole remains the first-line therapy for HIV-infected patients with oropharyngeal candidiasis due to fewer side effects compared to itraconazole 1

Fluconazole-Refractory Disease

• Itraconazole solution 200 mg once daily OR posaconazole suspension 400 mg twice daily for 3 days then 400 mg daily for up to 28 days 1, 4
• Alternatives include voriconazole 200 mg twice daily OR amphotericin B deoxycholate oral suspension 100 mg/mL 4 times daily 1, 4

Esophageal Candidiasis

• Oral fluconazole 200-400 mg (3-6 mg/kg) daily for a minimum of 14 days and at least 7 days following resolution of symptoms 1
• Fluconazole is preferred over itraconazole due to superior pharmacokinetics and better tolerability 1

Candidemia and Invasive Candidiasis (Non-Neutropenic Adults)

Echinocandins are the preferred first-line agents for most patients with candidemia:

• Caspofungin: 70-mg loading dose, then 50 mg daily 1
• Micafungin: 100 mg daily 1
• Anidulafungin: 200-mg loading dose, then 100 mg daily 1

When Fluconazole May Be Appropriate

• Fluconazole 800-mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) daily is acceptable for patients with mild to moderate illness who are hemodynamically stable, have no recent azole exposure, and are not at high risk for C. glabrata infection 1
• Fluconazole should be avoided in patients with suspected endocardial or CNS involvement; use fungicidal agents instead 1

Step-Down Therapy

• Transition to oral fluconazole 400 mg daily is reasonable after clinical improvement on echinocandin therapy for fluconazole-susceptible organisms (C. albicans, C. parapsilosis, C. tropicalis) 1

Duration and Adjunctive Measures

• Treat for 2 weeks after documented clearance of Candida from bloodstream and resolution of symptoms 1
• Central venous catheter removal is strongly recommended 1

Urinary Tract Candidiasis

Cystitis (Fluconazole-Susceptible Organisms)

• Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks 1
• Removal of indwelling bladder catheter is strongly recommended if feasible 1

Fluconazole-Resistant Species (C. glabrata, C. krusei)

• Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days OR oral flucytosine 25 mg/kg 4 times daily for 7-10 days 1
• Amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) may be useful for fluconazole-resistant cystitis 1

Pyelonephritis

• Oral fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks for fluconazole-susceptible organisms 1
• Elimination of urinary tract obstruction is strongly recommended 1

Neonatal Disseminated Candidiasis

• Amphotericin B deoxycholate 1 mg/kg daily is the primary recommendation 1
• Fluconazole 12 mg/kg IV or oral daily is a reasonable alternative in patients not on fluconazole prophylaxis 1
• Echinocandins should be used with caution and generally limited to salvage therapy 1

Critical Pitfalls and Caveats

Species-Specific Considerations

• Avoid fluconazole for C. krusei (intrinsically resistant) and use caution with C. glabrata (often reduced susceptibility) 1, 5
• Echinocandins have decreased activity against C. parapsilosis; fluconazole is preferred for this species 1

Drug Interactions

• Avoid oral fluconazole in patients taking clopidogrel due to CYP2C19 inhibition that reduces antiplatelet effect and increases cardiovascular risk 4
• Consider topical agents (clotrimazole, miconazole) for 7-14 days in these patients 4

Resistance Prevention

• Do not use azole therapy in patients with recent azole exposure or prophylaxis to minimize resistance risk 2
• Obtain fungal culture and susceptibility testing to identify resistant species 4

Asymptomatic Candiduria

• Does not require treatment in males unless the patient is neutropenic or undergoing urologic procedures 2