What is the appropriate treatment for a female of reproductive age with a urinary tract infection or vaginal infection, given a urine panel showing medium levels of Candida albicans and Ureaplasma urealyticum, low levels of Gardnerella vaginalis and Streptococcus agalactiae (Group B), and no detection of other common pathogens?

Treatment Approach for Vaginal Infection with Mixed Organisms

Treat the symptomatic vulvovaginal candidiasis with fluconazole 150 mg as a single oral dose, and do not treat the other detected organisms (Gardnerella vaginalis, Ureaplasma urealyticum, or Streptococcus agalactiae) unless the patient has specific symptoms of bacterial vaginosis or is pregnant. 1

Primary Pathogen Identification

The panel shows medium levels of Candida albicans, which is the clinically significant finding requiring treatment in a symptomatic patient. 1

• Vulvovaginal candidiasis typically presents with itching, burning with urination, redness, soreness, and thick white vaginal discharge resembling cottage cheese. 1
• The presence of medium-level Candida albicans on multiplex NAAT is FDA-cleared for symptomatic females and indicates active yeast vaginitis. 2

Treatment for Candida albicans

Administer fluconazole 150 mg as a single oral dose. 1

• This is the standard FDA-approved treatment for vaginal candidiasis. 1
• Fluconazole works by stopping excessive yeast growth in the vagina. 1
• The patient should be counseled that if pregnant or planning to become pregnant, she should inform her provider immediately, as fluconazole requires contraception during treatment and for 1 week after the final dose. 1

Management of Gardnerella vaginalis (Low Level)

Do not treat low-level Gardnerella vaginalis unless the patient has clinical signs of bacterial vaginosis. 2

• Gardnerella vaginalis is detected in vaginal cultures of approximately 50% of normal women and does not require treatment in the absence of symptoms. 2
• Bacterial vaginosis requires three of four clinical criteria: homogeneous white noninflammatory discharge, clue cells on microscopy, vaginal pH >4.5, and positive whiff test. 2
• The presence of G. vaginalis alone on molecular testing does not establish the diagnosis of bacterial vaginosis, as microbiome-based multiplex NAATs show greater specificity than tests identifying only G. vaginalis. 2
• If bacterial vaginosis is clinically confirmed, treat with metronidazole 500 mg orally twice daily for 7 days or metronidazole gel 0.75% one applicator intravaginally daily for 5 days. 2

Management of Ureaplasma urealyticum (Medium Level)

Do not treat Ureaplasma urealyticum in the absence of urethritis symptoms or if the patient is not pregnant. 2

• The role of Ureaplasma species in causing urinary tract pathology is debated, with recent data suggesting U. urealyticum (but not U. parvum) may be an etiological agent in non-gonococcal urethritis. 2
• Ureaplasma urealyticum is frequently found in urine cultures without causing symptomatic infection, particularly in women. 3, 4
• Treatment is only indicated if the patient has mucopurulent or purulent urethral discharge, dysuria, or urethral pruritus consistent with urethritis. 2
• If urethritis is confirmed, treat with azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for 7 days. 2

Management of Streptococcus agalactiae/Group B Strep (Low Level)

Do not treat low-level Group B Streptococcus unless the patient is pregnant. 2

• Asymptomatic bacteriuria should not be treated in non-pregnant women, as this promotes antimicrobial resistance. 5, 6
• Group B Streptococcus colonization in the urinary tract of non-pregnant women does not require treatment. 7
• If the patient is pregnant, any level of Group B Streptococcus in urine indicates heavy colonization and requires treatment with antibiotics during labor for intrapartum prophylaxis. 2

Critical Clinical Context Assessment

Determine whether symptoms suggest vaginitis (pH <4.5) versus bacterial vaginosis (pH >4.5) versus urinary tract infection. 2

• Yeast vaginitis typically has vaginal pH <4.5, while bacterial vaginosis and trichomoniasis have pH >4.5. 2
• True urinary tract infection symptoms include frequency, urgency, dysuria, and suprapubic pain, which differ from vaginal discharge and vulvar irritation. 6
• The specimen type matters: this appears to be a urine panel, but the organisms detected (particularly Candida and Gardnerella) are more consistent with vaginal contamination or a vaginal specimen mislabeled as urine. 2, 4

Common Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria or colonization, as this is the most common error leading to unnecessary antibiotic use and resistance. 5, 6
• Do not assume all detected organisms require treatment—molecular panels detect colonization as well as infection, and clinical correlation is essential. 2
• Do not use broad-spectrum antibiotics for organisms that may represent normal flora or contamination. 5
• Do not obtain post-treatment cultures if the patient becomes asymptomatic after fluconazole treatment. 5
• Verify pregnancy status before prescribing fluconazole, as it requires contraception during and for 1 week after treatment. 1