What is the first-line treatment for yeast infections?

First-Line Treatment for Yeast Infections

For vulvovaginal candidiasis, use oral fluconazole 150 mg as a single dose or topical azoles (clotrimazole, miconazole) for 1-7 days; for oropharyngeal candidiasis, use oral fluconazole 100-200 mg daily for 7-14 days; and for invasive candidiasis/candidemia, use echinocandins (caspofungin, micafungin, or anidulafungin) as first-line therapy. 1

Vulvovaginal Candidiasis

For uncomplicated vulvovaginal yeast infections, either topical azoles or oral fluconazole are equally effective first-line options. 1

• Oral fluconazole 150 mg as a single dose is the most convenient systemic option 1
• Topical azoles (clotrimazole or miconazole) applied intravaginally for 1-7 days achieve high clinical cure rates equal to oral therapy 1
• No single topical agent is superior to another; choice depends on patient preference and convenience 1
• Clinical cure rates for fluconazole reach 66.6% compared to 60% for itraconazole in comparative studies 2

Oropharyngeal Candidiasis

The treatment approach depends on disease severity:

• For mild disease: Clotrimazole troches 10 mg five times daily for 7-14 days OR miconazole mucoadhesive buccal 50-mg tablet applied once daily for 7-14 days 1
• For moderate to severe disease: Oral fluconazole 100-200 mg daily for 7-14 days 1

Esophageal Candidiasis

Oral fluconazole 200-400 mg daily for a minimum of 14 days and at least 7 days following resolution of symptoms is the recommended first-line treatment 1

Candidemia and Invasive Candidiasis

Echinocandins are the preferred first-line agents for most patients with candidemia and invasive candidiasis. 3, 1

For Non-Critically Ill Patients:

• Fluconazole 800-mg loading dose, then 400 mg daily is acceptable for hemodynamically stable patients with no recent azole exposure and likely fluconazole-susceptible isolates 3, 1
• This applies to patients with mild to moderate illness 3

For Critically Ill Patients:

Echinocandins are strongly recommended: 3, 1

• Caspofungin: Loading dose 70 mg, then 50 mg daily 3
• Micafungin: 100 mg daily 3
• Anidulafungin: Loading dose 200 mg, then 100 mg daily 3

Alternative for Specific Situations:

• Liposomal amphotericin B 3-5 mg/kg daily is advocated as first-line therapy in patients with sepsis/septic shock presenting with candidemia or endophthalmitis, prior exposure to echinocandins and/or fluconazole, or infections by Candida glabrata 3
• This recommendation addresses pharmacokinetic concerns about echinocandin penetration into certain body compartments 3

Duration of Therapy:

Continue treatment for 2 weeks after documented clearance of Candida from the bloodstream and resolution of symptoms 3

Intra-Abdominal Candidiasis

The choice of antifungal therapy is the same as for candidemia, with echinocandins preferred for critically ill patients. 3

• Empirical antifungal therapy should be considered for patients with clinical evidence of intra-abdominal infection and significant risk factors including recent abdominal surgery, anastomotic leaks, or necrotizing pancreatitis 3
• An echinocandin should be used as empirical therapy in critically ill patients with community-acquired or healthcare-associated intra-abdominal infections 3
• First-line fluconazole therapy is preferable only in non-critically ill cases 3
• Treatment duration is typically 2-3 weeks based on expert recommendations 3

Urinary Tract Candidiasis

For cystitis due to fluconazole-susceptible organisms, use oral fluconazole 200 mg daily for 2 weeks. 1

• Removal of indwelling bladder catheter is strongly recommended if feasible 1

Neonatal Disseminated Candidiasis

Amphotericin B deoxycholate 1 mg/kg daily is the primary treatment. 1

• Fluconazole 12 mg/kg IV or oral daily is a reasonable alternative in patients not on fluconazole prophylaxis 1

Critical Species-Specific Considerations

Candida glabrata:

An echinocandin is preferred due to reduced azole susceptibility 3, 1

• EUCAST guidelines consider C. glabrata resistant to azole agents 3
• Liposomal amphotericin B is an alternative 3

Candida parapsilosis:

Fluconazole is preferred as echinocandins have decreased activity against this species 3, 1

Candida krusei:

Avoid fluconazole due to intrinsic resistance; use echinocandins, liposomal amphotericin B, or voriconazole 3, 1

Candida auris:

Echinocandins are recommended as first-line therapy due to extensive azole resistance 3

• Overall susceptibility rate to fluconazole is only 10.7% 3

Important Clinical Pitfalls

• Catheter removal is strongly recommended for non-neutropenic patients with candidemia 3
• Recent azole exposure mandates use of echinocandins rather than fluconazole 3
• De-escalation to fluconazole is appropriate only after clinical stability is achieved, follow-up cultures are negative, and isolate susceptibility is confirmed 3
• Recurrent vulvovaginal candidiasis requires long-term prophylactic maintenance regimens, with oral fluconazole as first-line 4