Should asymptomatic yeast infections be treated, especially in patients who are pregnant, immunocompromised, or have a history of recurrent infections?

Should Asymptomatic Yeast Infections Be Treated?

Asymptomatic yeast infections should NOT be treated in most patients, with critical exceptions for neonates with low birth weight, severely immunocompromised patients with fever and candiduria, and pregnant women where treatment remains controversial but may be considered to reduce potential pregnancy complications. 1

General Principle for Asymptomatic Candiduria

• If no predisposing condition is identified in an asymptomatic patient with candiduria, only observation is warranted. 1
• Removal of an indwelling urinary catheter alone is often sufficient to clear candiduria without any antifungal therapy. 1
• Antifungal therapy is not indicated for patients with asymptomatic candiduria in the absence of specific high-risk conditions. 1
• The presence of yeast in urine must be evaluated in the clinical context to determine relevance and need for treatment—asymptomatic candiduria rarely represents candidemia (<5% of cases). 1

Critical Exceptions Requiring Treatment

Severely Immunocompromised Patients

• Neonates with low birth weight and severely immunocompromised patients with fever and candiduria require aggressive treatment, as disseminated candidiasis must be considered. 1
• Neutropenic patients with persistent unexplained fever and asymptomatic candiduria may have disseminated candidiasis and warrant treatment. 1

Pregnant Women

• The evidence for treating asymptomatic vulvovaginal yeast infections in pregnancy is insufficient and controversial. 2
• A 2023 systematic review and meta-analysis found no strong statistical evidence of increased risk for preterm birth or other adverse perinatal outcomes in pregnant women with either symptomatic or asymptomatic vulvovaginal yeast infection (OR 1.12,95% CI 0.94-1.35 for asymptomatic participants). 2
• The American College of Obstetricians and Gynecologists recommends treating all symptomatic pregnant women with bacterial vaginosis or trichomoniasis to reduce preterm labor risk, but this recommendation does not extend to asymptomatic yeast infections. 3
• Despite limited evidence, some clinicians may consider treatment in pregnancy given theoretical concerns about inflammation, but this should be weighed against unnecessary antifungal exposure. 2

Patients Who Should NOT Be Treated

Asymptomatic Vulvovaginal Colonization

• Many individuals have asymptomatic oropharyngeal or vulvovaginal colonization with Candida species, and treatment frequently does not result in microbiological cure. 1
• Vulvovaginal candidiasis is common among healthy adult women and is unrelated to HIV-1 status; asymptomatic colonization alone does not warrant treatment. 1
• Oropharyngeal fungal cultures are of little benefit in asymptomatic patients because colonization is common and treatment does not guarantee eradication. 1

HIV-Infected or Immunocompromised Patients Without Symptoms

• Immunocompromised or HIV-infected women with asymptomatic yeast colonization should be treated with identical regimens as immunocompetent women—meaning no treatment for asymptomatic cases. 3
• Recurrent vulvovaginal candidiasis alone should not be considered a sentinel of HIV-1 infection among women. 1

Important Caveats

Risk of Antifungal Resistance

• Unnecessary treatment of asymptomatic colonization encourages women to self-diagnose and chronically expose themselves to antifungal medications, promoting fungal resistance. 4
• Multiple courses of therapy or suppressive therapy for recurrent infection are major risk factors for development of azole-refractory infections. 1
• The widespread availability of over-the-counter antifungal medications has led to misdiagnosis and unnecessary treatment, contributing to resistance patterns. 4

When to Reconsider the Diagnosis

• Asymptomatic candiduria in the absence of a urinary catheter may actually represent disseminated candidiasis in specific high-risk populations (neutropenic patients, severely immunocompromised). 1
• If predisposing conditions exist (indwelling catheters, recent antibiotics, immunosuppression), management of the underlying condition is the priority rather than antifungal treatment. 1

Special Urologic Situations

• Several conditions require aggressive treatment of persistent candiduria even in asymptomatic patients: planned urologic procedures, neutropenia with fever, and neonates with low birth weight. 1
• For patients undergoing urologic instrumentation or surgery, treatment may be warranted to prevent ascending infection, though this represents a different clinical scenario than simple asymptomatic colonization. 1