From the Guidelines
The next step in managing this 85-year-old afebrile man with a chronic suprapubic catheter and persistent candiduria despite tube change is to avoid antifungal treatment unless the patient is symptomatic or at high risk for invasive infection. Asymptomatic candiduria in patients with chronic indwelling catheters generally does not require treatment, as the fungal colonization will likely persist despite therapy as long as the catheter remains in place 1. If the patient develops symptoms such as fever, suprapubic pain, or signs of systemic infection, or if he is immunocompromised or scheduled for urologic procedures, then treatment would be warranted. In such cases, oral fluconazole 400 mg initially followed by 200 mg daily for 7-14 days would be appropriate for susceptible Candida species, as recommended by the Infectious Diseases Society of America 1. For resistant species, alternative options include amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) or IV echinocandins for systemic infections. The persistence of candiduria despite catheter change suggests biofilm formation on the catheter surface, which shields the fungi from both host defenses and antifungal agents. Regular catheter changes (every 4-6 weeks) should continue as part of routine care, but treatment of asymptomatic candiduria in this setting typically leads to recurrence without clinical benefit.
Some key points to consider in the management of this patient include:
- Elimination of predisposing factors, such as indwelling bladder catheters, is recommended whenever feasible 1
- Treatment with antifungal agents is NOT recommended unless the patient belongs to a group at high risk for dissemination 1
- Patients undergoing urologic procedures should be treated with oral fluconazole or AmB deoxycholate for several days before and after the procedure 1
- Fluconazole is the drug of choice for treating Candida UTI, due to its high concentrations in the urine and efficacy against most Candida species 1
Given the patient's current asymptomatic status and the lack of high-risk factors for dissemination, the most appropriate course of action is to avoid antifungal treatment and continue with routine catheter care.
From the FDA Drug Label
For the treatment of Candida urinary tract infections and peritonitis, daily doses of 50 to 200 mg have been used in open, noncomparative studies of small numbers of patients. The next step is to treat the patient with oral fluconazole at a daily dose of 50 to 200 mg. 2
From the Research
Management of Candiduria
The patient in question is an 85-year-old afebrile man with a chronic suprapubic tube and persistent candiduria despite tube change. The next step in managing this patient involves considering the following options:
- Assessing the need for treatment: Since the patient is asymptomatic, the presence of Candida in the urine may not necessarily warrant antifungal therapy, as indicated by studies 3, 4.
- Risk factors and complications: The patient's age, presence of a chronic suprapubic tube, and persistent candiduria despite tube change are important considerations. However, the patient's afebrile status suggests that the infection may not be causing significant systemic symptoms.
- Treatment options: If treatment is deemed necessary, fluconazole is the antifungal agent of choice for symptomatic Candida urinary tract infections, achieving high urine concentrations with the oral formulation 3, 4. Other options like amphotericin B or flucytosine are rarely used.
Diagnostic Considerations
Before initiating treatment, it may be helpful to:
- Repeat urine culture: To confirm the persistence of candiduria and rule out other potential pathogens.
- Assess for underlying complications: Such as urinary obstruction or other urological issues that may be contributing to the persistence of candiduria.
- Consider imaging studies: Like renal ultrasound to evaluate for any underlying anatomical abnormalities or complications.
Treatment Approach
Given the patient's asymptomatic status, the initial approach may involve:
- Monitoring: Close observation to assess for the development of symptoms or complications.
- Fluconazole therapy: If treatment is deemed necessary, oral fluconazole may be considered, given its efficacy in achieving high urinary levels and treating symptomatic Candida urinary tract infections 3, 4.
It is essential to weigh the potential benefits and risks of treatment in this asymptomatic patient, considering the potential for adverse effects and the development of antifungal resistance.