How many doses of Diflucan (fluconazole) are recommended for a patient with a yeast infection and bacterial vaginosis?

Fluconazole Dosing for Yeast Infection with Bacterial Vaginosis

For uncomplicated vulvovaginal candidiasis, give a single oral dose of fluconazole 150 mg, but note that bacterial vaginosis requires separate antibiotic treatment as fluconazole has no antibacterial activity. 1, 2

Treatment Algorithm Based on Severity

Uncomplicated Vulvovaginal Candidiasis

• Single dose: fluconazole 150 mg orally once 1, 2
• This achieves clinical cure or improvement in 94-99% of patients at 14 days 3, 4
• Symptoms typically resolve within 48-72 hours 1

Severe Acute Vulvovaginal Candidiasis

• Fluconazole 150 mg every 72 hours for a total of 2-3 doses 1, 5
• The 2-dose regimen achieves significantly higher clinical cure rates in severe disease (P=0.015) 6
• This extended regimen provides superior mycologic eradication compared to single-dose therapy 6

Recurrent Vulvovaginal Candidiasis

• Induction therapy: 10-14 days with topical agent or oral fluconazole 1
• Maintenance: fluconazole 150 mg weekly for 6 months 1, 5
• This achieves symptom control in >90% of patients 5

Critical Diagnostic Considerations Before Treatment

Confirm the diagnosis with wet mount preparation using 10% KOH to demonstrate yeast or hyphae, and verify normal vaginal pH (4.0-4.5) 1, 5

• If wet mount is negative, obtain vaginal culture for Candida species identification 1, 5
• This is essential because treatment failure often indicates non-albicans species requiring different therapy 1, 6

Common Clinical Pitfall

Do not assume treatment failure with topical agents means you should simply increase fluconazole dosing—this often indicates Candida glabrata or other non-albicans species that are inherently azole-resistant. 5

For Suspected or Confirmed C. glabrata

• Intravaginal boric acid 600 mg daily for 14 days 1, 5
• Alternative: nystatin intravaginal suppositories 100,000 units daily for 14 days 1
• Azole therapy is unreliable for non-albicans species 1

Addressing the Bacterial Vaginosis Component

Bacterial vaginosis requires separate treatment with antibiotics (metronidazole or clindamycin), as fluconazole has zero antibacterial activity. 2

• Treat both conditions concurrently but with different agents
• The presence of bacterial vaginosis does not change the fluconazole dosing for candidiasis
• Confirm bacterial vaginosis diagnosis with pH >4.5, positive whiff test, and clue cells on microscopy

Safety Profile

Fluconazole is well-tolerated with mild side effects in 17-27% of patients, most commonly diarrhea and nausea (1.9% each) 3, 7

• No serious adverse effects reported in clinical trials 6, 7
• Single-dose therapy has equivalent safety to multi-day topical regimens 3, 8, 4