What is the appropriate treatment for a urinary tract infection with leukocytes and budding yeast in the urine?

From the Guidelines

The most appropriate treatment for a urinary tract infection with leukocytes and budding yeast in the urine is fluconazole 200mg on day 1 followed by 100mg daily for 7-14 days, alongside an antibiotic such as nitrofurantoin or trimethoprim-sulfamethoxazole to target the bacterial component of the infection. This approach is based on the most recent and highest quality evidence available, which emphasizes the importance of treating both bacterial and fungal pathogens in mixed urinary tract infections 1. The presence of leukocytes and budding yeast in the urine suggests a complex infection that requires a dual therapeutic approach.

Key Considerations

• The choice of antifungal agent is crucial, with fluconazole being the preferred option due to its efficacy, oral formulation, and high concentrations in the urine 1.
• For the bacterial component, antibiotics such as nitrofurantoin 100mg twice daily for 5-7 days or trimethoprim-sulfamethoxazole DS tablet twice daily for 3 days are typically recommended.
• Increased fluid intake is essential to help flush out the urinary system and support the treatment process.
• The presence of risk factors such as diabetes, recent antibiotic use, immunosuppression, or indwelling catheters should be considered when managing the infection.

Treatment Duration and Follow-Up

• The treatment duration for the fungal component is typically 7-14 days, depending on the severity of the infection and the patient's response to treatment 1.
• Patients should complete the full course of medication even if symptoms improve before finishing treatment to prevent recurrence and antimicrobial resistance.
• If symptoms persist after treatment, further evaluation with urine culture and sensitivity testing may be necessary to guide targeted therapy.

From the Research

Urinary Tract Infection Treatment

The presence of leukocytes and budding yeast in urine indicates a potential urinary tract infection (UTI) that may be caused by bacteria or fungi, such as Candida.

• The treatment approach depends on the causative agent and the severity of the infection.
• For bacterial UTIs, the choice of antibiotic therapy should be guided by local susceptibility patterns and the patient's medical history 2.
• Fluconazole is the antifungal agent of choice for treating Candida UTIs, achieving high urine concentrations with oral formulation 3.
• The recommended dose of fluconazole for symptomatic fungal UTI is 200 mg loading dose followed by 100 mg/day for at least four days 4.

Candida Urinary Tract Infections

• Candiduria can be a nonspecific finding, and most patients are colonized and do not require antifungal therapy 3.
• Removing predisposing factors, such as indwelling catheters and antibiotics, can clear candiduria in almost 50% of asymptomatic patients 3.
• Treatment options for Candida UTIs include fluconazole, amphotericin B, and flucytosine, although the latter two are rarely used 3.

Bacterial Urinary Tract Infections

• The recommended first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females includes nitrofurantoin, fosfomycin tromethamine, or pivmecillinam 2, 5.
• Second-line options include oral cephalosporins, fluoroquinolones, and β-lactams, such as amoxicillin-clavulanate 2.
• The choice of antibiotic therapy should consider the risk of resistance and the patient's medical history 2, 5.

Impact of Antibiotics on Yeast Flora

• Broad-spectrum antibiotics can disrupt the balance of the yeast flora in the human gut, leading to increased colonization by Candida species 6.
• Amoxicillin-clavulanate has been shown to cause a higher and more persistent increase in gastrointestinal colonization by yeasts compared to other antibiotics 6.