Mythbuster: ‘This patient’s tested positive for Candida – can you arrange a prescription?’

Dr Toni Hazell outlines why an incidental finding of Candida in a patient without symptoms of thrush does not automatically require a prescription

Women having swabs taken to investigate gynaecological symptoms such as irregular menstrual bleeding may frequently have a positive result for moderate Candida albicans growth – despite having no symptoms of vulvovaginal candidiasis (thrush).

This can lead to a request for a prescription, either from another healthcare professional in the service which carried out the tests, such as a sexual health or gynaecology clinic, or from the patient themselves if they happen to see the result via online access to their notes.

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In reality, however, asymptomatic thrush does not need to be treated. Any test risks throwing up an incidental finding and if we are not careful, this can lead to overdiagnosis and overtreatment.

Nurses in primary care need to have the confidence to explain to patients (and sometimes colleagues) when something is incidental and doesn’t need treating.

What’s the evidence-based approach?

Candida is often part of normal vaginal flora¹ and up to 20% of women may have asymptomatic Candida albicans colonisation detected on swabs done for another reason;² the prevalence increases to 30-40% during pregnancy.^2,3

The British Association for Sexual Health and HIV (BASHH) defines acute vulvovaginal candidiasis as a ‘first or single isolated presentation… patients typically present with signs and symptoms of acute vulvovaginitis and Candida species can be detected by microscopy or cultures’.³ Features of vulvovaginitis caused by thrush include whitish discharge with vulvovaginal soreness/itching. This guideline about how to treat therefore does not apply to those with no symptoms.

Pregnant women who have asymptomatic thrush may be keen to access treatment, but the BASHH guidelines state that there is no link between asymptomatic thrush in pregnancy and outcomes such as prematurity or low birth weight, and this is confirmed by a recent systematic review and meta-analysis.⁴ Pregnant women can therefore also be reassured that they do not need treatment.

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Avoiding the taking of unnecessary swabs in the first place will, of course, help to reduce overdiagnosis and treatment, as well as reducing healthcare costs.

Caveats

It is possible that a patient may not volunteer symptoms of thrush, especially when consulting for another reason. Also, the reality of primary care is that we might not always know why swabs have been done. GP practices are sometimes sent swab findings taken by other healthcare professionals.

One simple way to deal with this is to contact the woman to find out if she is symptomatic or not. If workload precludes this, on a routine basis women can be asked to go online or phone for their results and the result should be marked ‘thrush – needs treatment only if there are symptoms of itch or discharge’. The woman can then alert the practice if she is symptomatic so that a prescription or advice to obtain medication from a pharmacy can then be issued.

Key points

• Candida albicans is a normal commensal and does not need treatment in the absence of symptoms
• This is also the case for pregnant women
• We should avoid doing unnecessary swabs; this will reduce the risk of overdiagnosis of Candida

References

1. 1. Jeanmonod R, Jeanmonod D. Vaginal candidiasis. In: StatPearls. Treasure Island (FL), StatPearls Publishing 2021.
   2. NHS. West of Scotland Guideline: Genital Candiasis. 2024
   3. British Association for Sexual Health and HIV (BASHH). National guideline for the management of vulvovaginal candidiasis. 2019
   4. Schuster H, de Jonghe B, Limpens J. Asymptomatic vaginal Candida colonization and adverse pregnancy outcomes including preterm birth: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2020;2:100163

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