What is the treatment for candidiasis in a pregnant patient?

From the Guidelines

For pregnant patients with candidiasis, AmB is the treatment of choice for invasive candidiasis, while topical azole antifungals, such as clotrimazole or miconazole, are recommended for vulvovaginal candidiasis. According to the 2016 clinical practice guideline for the management of candidiasis by the Infectious Diseases Society of America 1, AmB is the preferred treatment for invasive candidiasis in pregnant women, as other options like fluconazole, itraconazole, posaconazole, and isavuconazole should be avoided due to potential birth defects. For vulvovaginal candidiasis, topical azole antifungals are the first-line treatment, with options like clotrimazole 1% cream or miconazole 2% cream applied vaginally once daily for 7 days being safe and effective 1.

Key Considerations

• The treatment approach may vary depending on the severity and type of candidiasis, with invasive candidiasis requiring AmB and vulvovaginal candidiasis being treated with topical azoles.
• Oral fluconazole should be avoided during pregnancy, especially in the first trimester, due to potential risks to the fetus 1.
• Topical azole medications work by disrupting the fungal cell membrane, preventing the growth and reproduction of Candida species while having minimal systemic absorption, making them safe for use during pregnancy 1.
• Patients should complete the full course of treatment even if symptoms improve before finishing the medication, and reevaluation is necessary if symptoms persist after treatment.

Treatment Options

• AmB for invasive candidiasis
• Clotrimazole 1% cream or miconazole 2% cream for vulvovaginal candidiasis
• Treatment can be initiated at any time during pregnancy when symptoms occur
• For severe or recurrent infections, a longer 14-day course may be necessary 1

From the FDA Drug Label

Vaginal candidiasis: Two adequate and well-controlled studies were conducted in the U. S. using the 150 mg tablet. The therapeutic cure rate, defined as a complete resolution of signs and symptoms of vaginal candidiasis (clinical cure), along with a negative KOH examination and negative culture for Candida (microbiologic eradication), was 55% in both the fluconazole group and the vaginal products group

The treatment for candidiasis in a pregnant patient is fluconazole 150 mg tablet.

• Key points:
  • The therapeutic cure rate was 55% in the fluconazole group.
  • The fluconazole regimen was comparable to the control regimen (clotrimazole or miconazole intravaginally for 7 days) both clinically and statistically at the one month post-treatment evaluation.
  • Approximately three-fourths of the enrolled patients had acute vaginitis and achieved 80% clinical cure, 67% mycologic eradication, and 59% therapeutic cure when treated with a 150 mg fluconazole tablet administered orally 2.

From the Research

Treatment Options for Candidiasis in Pregnant Patients

• The treatment for candidiasis in pregnant patients can be achieved through various methods, including vaginal and oral antifungals 3.
• Studies have shown that topical imidazole is more effective than nystatin for treating symptomatic vaginal candidiasis in pregnancy 4, 5.
• Miconazole nitrate administered intravaginally has been found to achieve comparable therapeutic and mycological cure rates in both pregnant and nonpregnant women 6.
• Treatment for seven days may be necessary in pregnancy, rather than the shorter courses more commonly used in non-pregnant women 4, 5.

Comparison of Treatment Methods

• A retrospective analysis of 61 pregnant women treated with vaginal or vaginal plus oral antifungals showed no significant differences in the recurrence of VVC in the first, second, and third trimesters 3.
• Imidazole drugs were found to be more effective than nystatin when treating vaginal candidiasis in pregnancy, with an odds ratio of 0.21 (95% confidence interval 0.16 to 0.29) 4, 5.
• Single-dose treatment was found to be less effective than three or four days treatment, and treatment lasting for four days was less effective than treatment for seven days 4, 5.

Safety and Efficacy of Treatment

• Local treatment of VVC has several advantageous features, including a low rate of adverse events, safe utilization during pregnancy, and breastfeeding 3.
• Miconazole nitrate was found to be significantly better than nystatin, clotrimazole, and butoconazole in treating vaginal candidiasis during gestation 6.
• The choice of therapy for vaginal candidiasis in pregnant patients will continue to be based on individual clinician preference, until further information is available 7.