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

Treatment of Yeast Infection

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 as first-line therapy. 1, 2

Vulvovaginal Candidiasis (Most Common Presentation)

First-Line Options

Topical azole therapy:

• Clotrimazole 1% cream 5g intravaginally for 7-14 days OR clotrimazole 100mg vaginal tablet daily for 7 days 2
• Miconazole 2% cream 5g intravaginally for 7 days OR miconazole 200mg vaginal suppository daily for 3 days 2
• Multi-day regimens (3- and 7-day courses) achieve 80-90% cure rates and are preferred over single-dose treatments for potentially severe cases 2
• Topical azoles are fungistatic and work by limiting fungal growth while epidermal turnover sheds the organism 3

Oral systemic therapy:

• 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
• Women of childbearing potential should use contraception during treatment and for 1 week after the final dose 4

Recurrent Vulvovaginal Candidiasis

For recurrent infections (≥4 episodes per year):

• Initial treatment: Fluconazole 150 mg single dose 1
• Maintenance therapy: Fluconazole 150 mg weekly for 6 months 1
• Address predisposing factors including uncontrolled diabetes, antibiotic use, immunosuppression, and poor hygiene 1

Oral Candidiasis (Thrush)

Mild Disease

• Clotrimazole troches 10 mg five times daily for 7-14 days 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 5, 2

Moderate to Severe Disease

• Oral fluconazole 100-200 mg daily for 7-14 days 5, 2
• For patients unable to tolerate oral therapy, use intravenous fluconazole 400 mg (6 mg/kg) daily OR an echinocandin 5

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 5

Urinary Candidiasis

Asymptomatic Candiduria

• Treatment is NOT recommended unless the patient is neutropenic, undergoing urologic procedures, or is a very low-birth-weight infant (<1500g) 5, 2
• Elimination of indwelling bladder catheters is strongly recommended when feasible 5

Symptomatic Cystitis

• For fluconazole-susceptible organisms: Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks 5, 2
• Remove indwelling bladder catheter if present 5, 2
• 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

Male Genital Yeast Infections

• Topical azole antifungals are first-line treatment 1
• Asymptomatic candiduria in males does not require treatment unless neutropenic or undergoing urologic procedures 1

Critical Considerations and Pitfalls

Contraindications to fluconazole:

• Do not use with quinidine, erythromycin, or pimozide 4
• Avoid in patients with recent azole exposure or prophylaxis due to increased resistance risk 1

Special populations:

• Pregnancy: Discuss risks/benefits with healthcare provider; contraception required during treatment and for 1 week after 4
• Breastfeeding: Fluconazole passes into breastmilk; discuss feeding options 4
• Elderly patients: Consider renal function if using systemic therapy; oral fluconazole may be preferred over topical agents due to manual dexterity issues 2
• Liver/kidney/heart problems: Inform provider before starting fluconazole 4

Common pitfalls:

• Treating asymptomatic candiduria leads to unnecessary medication exposure and higher recurrence rates 2
• Stopping treatment when skin appears healed (usually after 1 week) causes higher recurrence with fungistatic drugs compared to fungicidal agents 3
• Failing to address predisposing factors in recurrent infections 1

Resistance patterns:

• For fluconazole-resistant organisms, use amphotericin B deoxycholate or echinocandins 1
• C. krusei is inherently fluconazole-resistant; use amphotericin B deoxycholate 0.3-0.6 mg/kg daily 5