What is the recommended treatment for a pregnant woman with Group B strep (Streptococcus agalactiae) vaginal infection and candida (fungal) infection?

Treatment of Group B Streptococcus Vaginal Colonization with Concurrent Candida Infection

Do not treat GBS vaginal colonization outside of labor—only treat the candida infection now, and reserve GBS treatment for intrapartum prophylaxis during active labor. 1

Critical Management Principle for GBS Colonization

Antimicrobial agents should NOT be used before the intrapartum period to treat GBS colonization, as such treatment is not effective in eliminating carriage or preventing neonatal disease and may cause adverse consequences. 1, 2

• The CDC explicitly states this is a Grade D-I recommendation (evidence supports not doing this intervention). 1
• Prenatal antibiotic treatment of GBS colonization does not prevent neonatal disease and promotes antibiotic resistance. 1, 2
• GBS colonization is only treated during active labor to prevent early-onset neonatal disease. 2

Treatment Algorithm

Step 1: Treat the Candida Infection Now

For uncomplicated vulvovaginal candidiasis, use topical azole therapy or oral fluconazole (if not pregnant). 1, 3, 4

• Topical azole options (all equally effective): 3, 4

  • Clotrimazole 1% cream 5g intravaginally daily for 7-14 days
  • Miconazole 2% cream 5g intravaginally daily for 7 days
  • Terconazole 0.4% cream 5g intravaginally daily for 7 days

• Oral option (if not pregnant): 3, 4

  • Fluconazole 150 mg orally as a single dose

• If pregnant, use only topical azoles (oral fluconazole is not recommended during pregnancy). 3, 4, 5

Step 2: Reserve GBS Treatment for Labor

If pregnant, plan for intrapartum antibiotic prophylaxis during labor with penicillin G or ampicillin. 1, 2

• Preferred regimen: Penicillin G 5 million units IV initially, then 2.5 million units IV every 4 hours until delivery. 1
• Alternative regimen: Ampicillin 2 g IV initially, then 1 g IV every 4 hours until delivery. 1
• Penicillin is preferred due to its narrow spectrum of activity. 1

Step 3: Penicillin Allergy Considerations (for future intrapartum prophylaxis)

For women not at high risk for anaphylaxis: 1, 2, 6

• Cefazolin 2 g IV initially, then 1 g IV every 8 hours until delivery. 1, 6

For women at high risk for anaphylaxis (history of anaphylaxis, angioedema, urticaria, or asthma): 1, 2

• Clindamycin 900 mg IV every 8 hours until delivery (if susceptible on testing). 1
• Erythromycin 500 mg IV every 6 hours until delivery (if susceptible on testing). 1
• Vancomycin 1 g IV every 12 hours until delivery (if susceptibility unknown or resistant). 1

Special Circumstances

If GBS is Found in Urine (Not Just Vaginal Colonization)

GBS bacteriuria at any concentration during pregnancy requires immediate treatment AND intrapartum prophylaxis during labor. 1, 2, 7

• Treat the UTI with standard oral antibiotics (amoxicillin 500 mg every 8 hours for 7-10 days). 2, 7
• Still provide intrapartum prophylaxis during labor even if the UTI was treated earlier in pregnancy. 1, 2, 7
• GBS bacteriuria indicates heavy genital tract colonization and increased risk to the neonate. 2, 7

If Planned Cesarean Delivery Before Labor

Women with planned cesarean delivery before rupture of membranes and onset of labor do not need intrapartum GBS prophylaxis. 1

• These women are at low risk for early-onset neonatal GBS disease. 1

Common Pitfalls to Avoid

• Do not attempt to "decolonize" GBS with antibiotics during pregnancy—this is ineffective and promotes resistance. 1, 2, 7
• Do not confuse GBS colonization with GBS urinary tract infection—only UTI requires prenatal treatment. 1, 2
• Do not use ampicillin for candida treatment—this will worsen the yeast infection while failing to eradicate GBS colonization. 1
• Do not forget that topical azoles require longer treatment courses (7-14 days) compared to oral fluconazole (single dose). 3, 4
• Do not use oral fluconazole if the patient is pregnant—only topical azoles are safe in pregnancy. 3, 4, 5

Why This Approach Matters

The dual infection requires understanding that these are fundamentally different clinical scenarios: candida causes symptomatic vaginitis requiring immediate treatment, while GBS colonization is asymptomatic and only poses risk to the neonate during labor. 1 Treating GBS colonization prenatally wastes antibiotics, promotes resistance, exposes the patient to unnecessary drug side effects, and provides zero benefit for neonatal outcomes. 1, 2