What is the first-line treatment for a patient presenting with a yeast infection?

First-Line Treatment for Yeast Infections

For uncomplicated vulvovaginal candidiasis, oral fluconazole 150 mg as a single dose or topical azole antifungals (clotrimazole, miconazole) for 1-7 days are equally effective first-line options. 1

Vulvovaginal Candidiasis (Most Common Presentation)

Oral therapy:

• Fluconazole 150 mg single dose is the preferred oral option 1
• Equally effective as topical therapy with superior convenience 1

Topical therapy:

• Clotrimazole or miconazole applied intravaginally for 1-7 days 1
• No single topical agent is superior to another; choice depends on patient preference 1
• Both achieve high clinical cure rates comparable to oral fluconazole 1

Oropharyngeal Candidiasis

Mild disease:

• Clotrimazole troches 10 mg five times daily for 7-14 days 1
• Alternative: Miconazole mucoadhesive buccal 50-mg tablet once daily for 7-14 days 1

Moderate to severe disease:

• Oral fluconazole 100-200 mg daily for 7-14 days 1
• This is particularly important in immunocompromised patients, including those with AIDS 2

Esophageal Candidiasis

• Oral fluconazole 200-400 mg daily for minimum 14 days and at least 7 days following symptom resolution 1
• This represents a step up in both dose and duration compared to oropharyngeal disease 3

Invasive Candidiasis/Candidemia (Hospitalized Patients)

First-line therapy:

• Echinocandins (caspofungin, micafungin, or anidulafungin) are the preferred agents for most hospitalized patients with candidemia 1, 3
• These are favored due to fungicidal activity, favorable safety profile, and minimal drug interactions 3

Alternative for selected patients:

• Fluconazole 800-mg loading dose, then 400 mg daily is acceptable for patients who are hemodynamically stable, have mild-to-moderate illness, and have no recent azole exposure 1, 3
• Treatment duration: minimum 2 weeks after documented clearance of Candida from bloodstream and resolution of symptoms 3

Critical Species-Specific Considerations

Candida parapsilosis:

• Fluconazole is preferred over echinocandins due to decreased echinocandin activity against this species 1, 3

Candida krusei:

• Intrinsically resistant to fluconazole; avoid fluconazole entirely 1, 4
• Use echinocandin or voriconazole 1

Candida glabrata:

• Often demonstrates reduced azole susceptibility 1, 4
• Echinocandins are preferred 3

Intra-Abdominal Candidiasis (Specialized Setting)

• Antifungal therapy is indicated when Candida is grown from intra-abdominal cultures in severe community-acquired or healthcare-associated infections 3
• Fluconazole is appropriate if C. albicans is isolated 3
• For critically ill patients or fluconazole-resistant species, echinocandins are recommended 3
• Liposomal amphotericin B is advocated as first-line in patients with sepsis/septic shock, prior azole/echinocandin exposure, or C. glabrata infections 3

Urinary Tract Candidiasis

• Oral fluconazole 200 mg daily for 2 weeks for cystitis due to fluconazole-susceptible organisms 1
• Remove indwelling bladder catheter if feasible—this is strongly recommended 1

Common Pitfalls to Avoid

• Do not use fluconazole empirically without considering local resistance patterns and recent azole exposure 3, 4
• Always remove central venous catheters in non-neutropenic patients with candidemia—this is strongly recommended and impacts mortality 3
• Avoid amphotericin B as initial therapy for invasive candidiasis due to toxicity unless echinocandins and azoles are contraindicated 3
• Do not undertreate duration—continue therapy for at least 2 weeks after blood culture clearance for candidemia, not just until clinical improvement 3