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Candida - female genital - Management
How should I manage treatment failure in women who are pregnant?

  • Review:
    • Check that treatments have been used as recommended.
    • Consider alternative diagnoses.
    • Reassess for other predisposing risk factors, and remove or control as far as possible.
  • Investigate:
    • Send a vaginal specimen for culture to identify:
      • A non-albicans Candida species.
      • A mixed infection such as candidiasis together with bacterial vaginosis or trichomoniasis (up to 10% of infections are mixed). See the CKS topics on Bacterial vaginosis and Trichomoniasis.
  • Manage:
    • Give general advice about avoiding local irritants (such as soaps and shower gels) and tight-fitting synthetic clothes.
    • If symptoms are improving, consider giving a second course of an intravaginal antifungal (clotrimazole or miconazole).
    • Do not use oral antifungals such as fluconazole or ketoconazole.
    • For vulval symptoms, consider prescribing a topical imidazole cream (e.g. clotrimazole) in addition to an intravaginal imidazole.
  • Refer, or seek specialist advice if:
    • Compliance has been a problem because of adverse effects.
    • Symptoms are not improving and treatment failure is unexplained.
    • The diagnosis is unclear.
Basis for recommendation
  • These recommendations are pragmatic advice. CKS found no evidence or national guidelines specifically on treatment failure of vulvovaginal candidiasis in pregnancy.
  • Review, investigation, referral:
  • Treatment:
    • The doses CKS has recommended for extended courses are estimates only, as published reviews and guidelines do not give details of what doses to use. Where possible CKS has recommended preparations that are licensed for extended use.
    • Intravaginal nystatin was recommended for non-albicans Candida species because experts believe (on the basis of laboratory evidence) that it is more effective than topical or oral azoles against Candida glabrata and other non-albicans Candida species [BASHH, 2002; FFPRHC and BASHH, 2006]. However, nystatin intravaginal cream is no longer available in the UK. The Centers for Disease Control recommend using any azole antifungal except fluconazole (but do not cite any supporting evidence) [CDC, 2006].
  • Safety:
    • Oral triazoles (fluconazole and itraconazole) are contraindicated in pregnant women.
      • Animal studies have found that high doses of itraconazole cause fetal abnormalities, and there are concerns that fluconazole may cause congenital defects [Weiner and Buhimschi, 2004].
    • Topical imidazoles (clotrimazole, econazole or miconazole) are safe to use in pregnant women.
      • Systemic absorption of clotrimazole and miconazole is minimal [Micromedex, 2010].
      • The available data suggest that there is no evidence of an increased risk of spontaneous abortions or malformations with clotrimazole compared with the background rate [NTIS, 2008].
      • There are fewer data on exposure to miconazole during pregnancy, but the available data do not indicate an increased risk [Schaefer et al, 2007; Micromedex, 2010].
      • However, the manufacturer of econazole has recently updated the Summary of Product Characteristics to state that it is not recommended in pregnancy [ABPI Medicines Compendium, 2010]. In animal studies, econazole was not shown to be teratogenic, but was foetotoxic. The significance of this effect in humans is unknown.
  • Girls between 12 and 16 years old:
    • Intravaginal treatments are generally not recommended for girls between 12 and 16 years old unless, as in this situation, they are sexually active, or there is no other alternative [BNF for Children, 2007].

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