What is the recommended treatment with Diflucan (fluconazole) for a patient with a suspected or confirmed yeast infection?

Oral Fluconazole (Diflucan) for Yeast Infections

For uncomplicated vulvovaginal candidiasis, a single oral dose of fluconazole 150 mg is the recommended first-line treatment, achieving clinical cure rates of 92-99% within 5 days. 1, 2

Treatment by Clinical Scenario

Uncomplicated Vulvovaginal Candidiasis

• Single dose: Fluconazole 150 mg orally once 3, 1
• This achieves therapeutic vaginal concentrations rapidly and sustains them long enough for clinical and mycological cure 1
• Clinical efficacy rates of 94-97% at 14-day follow-up, with 75% remaining cured at 35 days 4
• Equivalent efficacy to 7-day intravaginal clotrimazole therapy but with superior patient compliance 4

Recurrent Vulvovaginal Candidiasis (≥4 episodes/year)

• Induction phase: Fluconazole 150 mg every 72 hours for 3 doses 5
• Maintenance phase: Fluconazole 150 mg weekly for 6 months 3, 5
• This regimen keeps 90.8% of women disease-free at 6 months versus 35.9% with placebo 5
• Median time to recurrence extends to 10.2 months versus 4.0 months without maintenance 5
• Critical caveat: After stopping maintenance therapy, recurrence rates increase significantly, with only 42.9% remaining disease-free at 12 months 5

Complicated Vulvovaginal Candidiasis

For patients with severe symptoms, immunocompromise, diabetes, or non-albicans species, the single-dose regimen is insufficient 3

Symptomatic Candida Cystitis

• Fluconazole 200 mg (3 mg/kg) daily for 14 days 3, 6
• Treatment is indicated in symptomatic patients and high-risk asymptomatic patients (immunocompromised, neutropenic, neonates, or those undergoing urologic procedures) 3, 6

Candidemia and Invasive Candidiasis

For non-critically ill patients without recent azole exposure:

• Loading dose: Fluconazole 800 mg (12 mg/kg), then 400 mg (6 mg/kg) daily 3, 6
• Continue for 2 weeks after documented bloodstream clearance and symptom resolution 3

For critically ill patients or those with recent azole exposure:

• Echinocandins are preferred over fluconazole as initial therapy 3
• Fluconazole can be used for step-down therapy after 5-7 days once the patient is clinically stable with negative repeat blood cultures and fluconazole-susceptible isolates 3

Species-specific considerations:

• C. albicans: Fluconazole is appropriate 3
• C. glabrata: Higher-dose fluconazole 800 mg (12 mg/kg) daily only if susceptibility confirmed; otherwise echinocandins preferred 3
• C. krusei: Fluconazole-resistant; use echinocandin or voriconazole 3
• C. parapsilosis: Fluconazole preferred over echinocandins 3

Neonatal Disseminated Candidiasis

• Fluconazole 12 mg/kg IV or oral daily is a reasonable alternative to amphotericin B in neonates without prior fluconazole prophylaxis 3
• Amphotericin B deoxycholate 1 mg/kg daily remains the primary recommendation 3

Monitoring Requirements

For Candidemia

• Daily or every-other-day blood cultures until clearance documented 3
• Dilated fundoscopic examination within the first week to detect endophthalmitis 3, 6
• Clinical response assessment at 4-5 days; if no improvement, switch to echinocandin 6

For Urinary Tract Infections

• Follow-up urine cultures after treatment completion to confirm eradication 6
• Monitor for systemic symptoms suggesting dissemination 6

Common Pitfalls and Caveats

Do not use fluconazole in these situations:

• Critically ill patients with suspected candidemia (use echinocandin first) 3
• Patients with recent azole exposure or prophylaxis (resistance risk) 3, 7
• Known or suspected C. krusei infection (intrinsically resistant) 3
• Empiric therapy in neutropenic patients (use echinocandin or lipid amphotericin B) 3

Premature discontinuation risks:

• In immunocompromised patients, stopping therapy before complete resolution leads to relapse 6
• For candidemia, must continue for full 2 weeks after bloodstream clearance, not just symptom improvement 3

Resistance considerations:

• Patients with recurrent infections on long-term fluconazole maintenance do not develop resistance to C. albicans, but monitor for C. glabrata superinfection 5
• History of recurrent vaginitis predicts significantly lower cure rates (33/84 vs 177/266 without recurrence history) 4

Adverse Effects

• Mild gastrointestinal symptoms (nausea, abdominal discomfort) are most common 1, 2
• Generally well-tolerated with low discontinuation rates (<1% due to adverse effects) 5
• Minor laboratory abnormalities occur in approximately 9% but are clinically insignificant 2