What is the recommended treatment for an 18-week pregnant woman with a candida (fungal infection) positive urine test?

Treatment of Candiduria at 18 Weeks Gestation

For an 18-week pregnant woman with Candida-positive urine, treatment is only indicated if she has symptomatic urinary tract infection; asymptomatic candiduria does not require antifungal therapy and should be managed by removing predisposing factors such as indwelling catheters or unnecessary antibiotics. 1, 2, 3

Initial Assessment

Determine if treatment is necessary:

• Asymptomatic candiduria (no dysuria, frequency, urgency, or fever): No antifungal treatment is indicated 2, 3

  • Remove predisposing factors (catheters, antibiotics) which clears candiduria in approximately 50% of cases 2
  • Most candiduria represents colonization or contamination, not true infection 3

• Symptomatic Candida UTI (dysuria, frequency, urgency, suprapubic pain, or fever): Treatment is required 2, 3

Treatment Approach for Symptomatic Candida UTI at 18 Weeks

Since the patient is in the second trimester (18 weeks), oral fluconazole can be safely used as first-line therapy:

• Fluconazole is the preferred agent due to high urine concentrations, safety profile after the first trimester, and availability in oral formulation 2, 3
• The FDA warning about fluconazole teratogenicity (craniosynostosis, skeletal abnormalities) applies specifically to high-dose therapy (400-800 mg/day) during the first trimester only 1
• After the first trimester, azole antifungals such as fluconazole are considered safe 1

Dosing regimen:

• Standard fluconazole dosing for Candida UTI (typically 200-400 mg loading dose, then 100-200 mg daily for 7-14 days) 2, 3

Alternative Options

If fluconazole is contraindicated or ineffective:

• Amphotericin B (intravenous): Safe throughout pregnancy but requires IV administration and has significant toxicity 1
• Flucytosine: Achieves high urine concentrations but requires caution due to potential toxicity 2, 3

Critical Pitfalls to Avoid

• Do not treat asymptomatic candiduria - this leads to unnecessary antifungal exposure and does not improve outcomes 2, 3
• Do not confuse candiduria with vulvovaginal candidiasis - these are separate conditions requiring different management 1, 4
• Avoid echinocandins and newer azoles (voriconazole, posaconazole) for urinary tract infections as they fail to achieve adequate urine concentrations 2, 3
• Do not use bladder irrigation with antifungals - this has limited utility except in specific cases like fungus balls 3

Special Consideration for Vulvovaginal Candidiasis

If the patient has vulvovaginal candidiasis rather than candiduria:

• Topical azole antifungals (clotrimazole, miconazole) are preferred throughout pregnancy as vaginal therapy 1, 4
• Local treatment with vaginal tablets, ovules, or creams is the safest approach 4
• Treatment in the last 6 weeks of pregnancy reduces vertical transmission risk to the newborn 4