Candiduria in Pregnancy: Treatment Recommendations
Primary Recommendation
Asymptomatic candiduria in pregnancy does not require treatment in most cases; however, symptomatic urinary tract candidiasis should be treated with amphotericin B bladder irrigation or intravenous amphotericin B, avoiding systemic azoles entirely during the first trimester.
Clinical Context and Decision Algorithm
The provided evidence focuses primarily on vulvovaginal and oral candidiasis rather than candiduria specifically. However, the principles of antifungal safety in pregnancy apply directly to urinary tract candidal infections.
First Trimester Management
Systemic azole antifungals (fluconazole, itraconazole) must be strictly avoided during the first trimester due to FDA warnings about teratogenic effects, including craniosynostosis, characteristic facies, digital synostosis, and limb contractures ("fluconazole embryopathy") with high-dose fluconazole (≥400 mg daily) 1, 2, 3.
Amphotericin B is the safest systemic antifungal option during the first trimester for any fungal infection requiring systemic therapy, including candiduria 1, 2, 3.
For asymptomatic candiduria (fungal colonization without symptoms), close monitoring without treatment is appropriate unless the patient has risk factors such as urologic abnormalities, immunosuppression, or planned urologic procedures 4.
Second and Third Trimester Management
After the first trimester, oral azole antifungals such as fluconazole may be considered with caution if amphotericin B is not feasible and benefits clearly outweigh risks 1, 2, 3.
Amphotericin B remains the preferred option throughout pregnancy for severe or refractory candiduria, though its use is limited by intravenous administration requirements and potential toxicity 1, 4.
Neonates born to mothers on chronic amphotericin B therapy should be evaluated for renal dysfunction and hypokalemia 1.
Species-Specific Considerations
Candida glabrata is not sufficiently sensitive to usual antifungal dosages and may require high-dose fluconazole (800 mg daily for 2-3 weeks) after the first trimester, though this should be avoided when possible 5, 6.
Candida krusei is resistant to fluconazole and itraconazole; alternative agents must be considered 5, 6.
Candida albicans remains the most common species and generally responds well to standard therapies 5, 6.
Critical Safety Points
The FDA issued specific warnings in 2011 that long-term, high doses (400-800 mg/day) of fluconazole are associated with birth defects when used during the first trimester 1, 2.
Topical or local therapies cannot adequately treat candiduria, unlike vulvovaginal candidiasis where topical azoles are first-line 2, 5.
A 1994 study of 289 women who took fluconazole during pregnancy showed no harmful effects, but this predates the FDA warnings about high-dose therapy and should be interpreted cautiously 7.
Common Pitfalls to Avoid
Prescribing oral fluconazole for any indication during the first trimester is the most critical error to avoid, given clear teratogenic risks 1, 2, 3.
Treating asymptomatic candiduria unnecessarily in low-risk pregnant patients can expose them to medication risks without clear benefit 4.
Failing to obtain fungal culture and species identification in persistent or recurrent cases, which is essential for guiding appropriate therapy, particularly for non-albicans species 5, 6.
Discontinuing amphotericin B therapy prematurely due to concerns about toxicity without adequate assessment of treatment response and infection severity 1.
Monitoring Requirements
For women on any antifungal therapy during pregnancy, close clinical monitoring every 4-6 weeks is recommended to assess treatment response and detect any complications 3.
Repeat urine cultures should be obtained to document clearance of candiduria after completing therapy.
Consultation with infectious disease specialists is recommended for severe, refractory, or disseminated cases 1.