What is the recommended treatment for a patient with a yeast infection, considering their symptoms, medical history, and potential allergies?

Treatment of Yeast Infections

First-Line Treatment Recommendations

For uncomplicated vulvovaginal candidiasis, use either topical azole antifungals (clotrimazole or miconazole) applied intravaginally for 1-7 days OR a single oral dose of fluconazole 150 mg, both with equivalent efficacy and A-I level evidence. 1

Topical Azole Regimens (Preferred for Most Patients)

• Clotrimazole 1% cream 5g intravaginally for 7-14 days OR clotrimazole 100mg vaginal tablet daily for 7 days are effective first-line options 2
• Miconazole 2% cream 5g intravaginally for 7 days OR miconazole 200mg vaginal suppository daily for 3 days are equally effective alternatives 2
• Multi-day regimens (3- and 7-day courses) achieve 80-90% cure rates and are preferred over single-dose topical treatments for potentially severe or complicated cases 2
• Topical azoles are fungistatic, limiting fungal growth while depending on epidermal turnover to shed the fungus 3

Oral Fluconazole (Alternative First-Line)

• Fluconazole 150 mg as a single oral dose achieves 92-99% clinical cure rates at short-term evaluation and 88-91% efficacy at long-term follow-up 1
• This option is preferred for patients who cannot use topical preparations or prefer systemic therapy 2
• Contraindications include: concurrent use of quinidine, erythromycin, or pimozide; known allergy to fluconazole; and pregnancy (requires discussion of risks/benefits) 4
• Women of childbearing potential should use contraception during treatment and for 1 week after the final dose 4

Treatment by Anatomical Site

Oral Candidiasis (Thrush)

For mild disease:

• Clotrimazole troches 10 mg five times daily for 7-14 days (strong recommendation) 5, 2
• Miconazole mucoadhesive buccal 50-mg tablet applied once daily for 7-14 days 5, 2
• Nystatin suspension (100,000 U/mL) 4-6 mL four times daily for 7-14 days is an alternative 5, 2

For moderate to severe disease:

• Oral fluconazole 100-200 mg daily for 7-14 days is the recommended treatment 5, 2

For fluconazole-refractory oral candidiasis:

• 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 5
• Voriconazole 200 mg twice daily OR amphotericin B deoxycholate oral suspension 100 mg/mL four times daily are alternatives 5

Esophageal Candidiasis

• Oral fluconazole 200-400 mg (3-6 mg/kg) daily for 14-21 days is first-line therapy 5
• For patients unable to tolerate oral therapy: intravenous fluconazole 400 mg (6 mg/kg) daily OR an echinocandin (micafungin 150 mg daily, caspofungin 70-mg loading dose then 50 mg daily, or anidulafungin 200 mg daily) 5
• De-escalate to oral fluconazole 200-400 mg daily once the patient can tolerate oral intake 5

Urinary Candidiasis

Critical distinction: Treatment is NOT recommended for asymptomatic candiduria unless the patient is neutropenic, undergoing urologic procedures, or is a very low-birth-weight infant 5, 2

For symptomatic cystitis with fluconazole-susceptible organisms:

• Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks 5, 2
• Remove indwelling bladder catheter if feasible (strong recommendation) 5

For fluconazole-resistant C. glabrata:

• Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days OR oral flucytosine 25 mg/kg four times daily for 7-10 days 5

For C. krusei:

• Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 5

Male Genital Yeast Infections

• Topical azole antifungals are first-line treatment for uncomplicated male genital yeast infections 1

Recurrent Vulvovaginal Candidiasis

For patients with recurrent infections (≥4 episodes per year):

• Initial treatment with fluconazole 150 mg single dose, followed by maintenance therapy with fluconazole 150 mg weekly for 6 months 1
• Address predisposing factors including uncontrolled diabetes, antibiotic use, immunosuppression, and poor hygiene 1
• Chronic suppressive therapy with fluconazole 100 mg three times weekly can be used if recurrence continues 5

Special Populations and Considerations

HIV-Infected Patients

• Antiretroviral therapy is strongly recommended to reduce the incidence of recurrent oral and esophageal candidiasis 5
• Chronic suppressive therapy with fluconazole 100-200 mg three times weekly is recommended for recurrent esophagitis 5

Pregnancy and Breastfeeding

• Discuss risks and benefits of fluconazole use during pregnancy with the patient 4
• Fluconazole passes into breast milk; discuss feeding options with breastfeeding mothers 4

Patients with Comorbidities

• Verify liver and kidney function before prescribing fluconazole, as dose adjustments may be needed 4
• Consider heart problems, arrhythmias, and hypokalemia as these may affect treatment choice 4
• Elderly patients with manual dexterity issues may prefer oral fluconazole over topical applications 2

Resistance Patterns and Alternative Therapies

When to Suspect Resistance

• Do not use azole therapy in patients with recent azole exposure or prophylaxis, as this increases resistance risk 1
• For fluconazole-resistant organisms, use amphotericin B deoxycholate or echinocandins 1

Systemic/Invasive Candidiasis

For candidemia in non-neutropenic patients:

• An echinocandin (caspofungin 70-mg loading dose then 50 mg daily; micafungin 100 mg daily; anidulafungin 200-mg loading dose then 100 mg daily) is recommended as initial therapy 5
• Remove central venous catheters as early as possible when the source is presumed to be the CVC 5
• Transition to fluconazole (usually within 5-7 days) for clinically stable patients with susceptible isolates and negative repeat blood cultures 5
• Duration of therapy is 2 weeks after documented clearance from bloodstream and resolution of symptoms 5

Common Pitfalls to Avoid

• Do not treat asymptomatic candiduria in non-high-risk patients, as this leads to unnecessary medication exposure and higher recurrence rates 2
• Verify the diagnosis before treatment, especially in recurrent cases where other conditions may mimic yeast infections 2
• Ensure adequate treatment duration—patients often stop treatment when symptoms resolve, but this can lead to recurrence with fungistatic agents 3
• Check for drug interactions before prescribing fluconazole, particularly with quinidine, erythromycin, and pimozide 4
• Always combine oral antifungal treatment with topical therapy when treating severe dermatophytoses 6