In a 48-year-old male with well-controlled diabetes (HbA1c 5.5%) and a positive vaginal Candida culture who is already using topical Nystatin 100,000 U/g twice daily for 7 days, what additional treatment should be prescribed?

Treatment Recommendation for Male Genital Candidiasis

Add oral fluconazole 150 mg as a single dose immediately, as this is the preferred first-line treatment for uncomplicated genital candidiasis and will provide superior efficacy compared to topical nystatin alone. 1

Why Fluconazole Should Be Added

The IDSA guidelines clearly state that for uncomplicated Candida vulvovaginitis (which includes male genital candidiasis), a single 150-mg oral dose of fluconazole is recommended as first-line therapy with strong evidence (strong recommendation; high-quality evidence). 1 While the guidelines use the term "vulvovaginitis," the same principles apply to male genital candidiasis, which is anatomically analogous.

Key advantages of adding fluconazole:

• Single-dose convenience with clinical cure rates of 74-94% at 14-28 days post-treatment 2, 3
• Superior to nystatin, which has clinical cure rates of only 32-54% compared to 100% with fluconazole in some populations 4
• Systemic distribution ensures treatment of any subclinical urethral or deeper tissue involvement that topical therapy cannot reach 5, 6

Why Nystatin Alone Is Inadequate

Nystatin cream has significant limitations for this patient:

• Lower efficacy than azole antifungals for genital candidiasis 4
• Topical-only coverage misses potential urethral or systemic involvement 4
• The 7-day course you prescribed is shorter than the recommended 14 days for nystatin in genital candidiasis 1, 4

Diabetes Consideration

Although his diabetes is well-controlled (HbA1c 5.5%), this still classifies him as having "complicated" candidiasis due to the abnormal host factor. 1 The IDSA defines complicated vulvovaginal candidiasis as infection in an abnormal host, which includes diabetic patients regardless of control. 1

For complicated cases, the guidelines recommend:

• Longer treatment duration (>7 days of therapy) 1
• More aggressive initial therapy to prevent recurrence 1

Complete Treatment Plan

Immediate additions:

• Fluconazole 150 mg PO × 1 dose now (strong recommendation; high-quality evidence) 1
• Continue the nystatin cream but extend to 14 days total (not just 7 days) to align with guideline recommendations for complicated cases 1, 4

If no improvement in 48-72 hours:

• Consider fluconazole 150 mg every 72 hours for 2-3 total doses for severe acute candidiasis 1
• Obtain fungal culture with speciation to rule out non-albicans species (particularly C. glabrata), which may be azole-resistant 1

For recurrence prevention (given his diabetes):

• After initial clearance, consider maintenance fluconazole 150 mg weekly for 6 months if he develops recurrent infections (≥4 episodes per year) 1
• Emphasize hygiene, keeping the area dry, and optimizing diabetes control 7

Critical Pitfalls to Avoid

• Do not rely on topical nystatin alone for a diabetic patient—this is inadequate therapy by current standards 4
• Do not assume "vaginal yeast culture" is an error—the lab likely used standard terminology, but confirm the specimen source was actually from the genital area 1
• Do not ignore the possibility of urethral involvement in males, which requires systemic therapy 6
• Watch for treatment failure, which may indicate C. glabrata (requires 14 days of topical therapy or alternative agents like boric acid) 1