What is the recommended treatment for Candida (fungal infection) during pregnancy?

Treatment of Candida Infections During Pregnancy

For vaginal candidiasis during pregnancy, topical imidazole antifungals (such as clotrimazole or miconazole) are the recommended first-line treatment due to their proven efficacy and safety profile.

Treatment Recommendations by Infection Type

Vulvovaginal Candidiasis

• First-line treatment: Topical imidazole antifungals

  • Clotrimazole vaginal tablets/cream
  • Miconazole vaginal cream
  • Treatment duration should be 7 days during pregnancy (rather than shorter courses used in non-pregnant women) 1
  • Apply cream to vulva 2-3 times daily and use vaginal tablets/suppositories nightly 2

• Second-line treatment: Nystatin vaginal suppositories

  • Less effective than imidazoles but still safe during pregnancy 1, 3
  • Miconazole has been shown to be significantly more effective than nystatin in all three trimesters 3

Systemic Candida Infections

• First trimester: Intravenous amphotericin B is the drug of choice 4, 5

  • No reports of teratogenicity with amphotericin B 5
  • Avoid systemic azoles during first trimester due to potential teratogenic effects 4

• Second and third trimesters:

  • Fluconazole may be considered at lower doses (≤150 mg/day) 5
  • Amphotericin B remains an alternative throughout pregnancy 6

Important Considerations

Safety Concerns

• Topical imidazoles have minimal systemic absorption when applied to skin and are considered safe throughout pregnancy 5
• Vaginal application of imidazoles has higher absorption than topical skin application but is still considered safe, especially in later pregnancy 5
• Systemic fluconazole at high doses has been associated with birth defects when used in first trimester 4
• Ketoconazole, flucytosine, and griseofulvin should be avoided during pregnancy due to teratogenic potential 5

Treatment Duration

• Treatment for 7 days is more effective than 4-day regimens during pregnancy (odds ratio 11.7,95% CI 4.21-29.15) 1
• No significant difference between 7-day and 14-day treatment courses 1

Breastfeeding Considerations

• Fluconazole is compatible with breastfeeding 4
• Other azole antifungals should be avoided during breastfeeding 4

Monitoring and Follow-up

• Clinical cure rates with topical clotrimazole approach 90% after a 6-day treatment course 2
• Consider retreatment for persistent symptoms
• Monitor for recurrence, which can occur in approximately 7% of treated pregnant women 2

Common Pitfalls to Avoid

1. Using shorter treatment courses (less than 7 days) during pregnancy
2. Prescribing systemic azoles during the first trimester
3. Failing to treat male partners when indicated
4. Overlooking potential concurrent infections (e.g., trichomoniasis)

By following these evidence-based recommendations, clinicians can effectively treat candidal infections during pregnancy while minimizing risks to both mother and fetus.