How to manage funguria in a patient with a suprapubic (urinary catheter) tube?

From the Guidelines

Funguria in patients with suprapubic catheters generally does not require treatment unless the patient is symptomatic or at high risk for complications. For asymptomatic funguria, the primary approach is to change the suprapubic catheter, as fungi often form biofilms on catheter surfaces that cannot be eradicated without removing the device. If the patient develops symptoms such as fever, suprapubic pain, or signs of systemic infection, antifungal therapy is warranted. The preferred treatment for Candida species, which cause most fungal urinary infections, is fluconazole 400 mg orally as a loading dose followed by 200 mg daily for 7-14 days 1. For fluconazole-resistant species, amphotericin B bladder irrigation (50 mg/L of sterile water) for 5-7 days may be used, instilling 200-300 mL into the bladder for 30 minutes four times daily. Preventive measures include:

• Maintaining closed drainage systems
• Proper perineal hygiene
• Minimizing unnecessary antibiotic use which can promote fungal overgrowth Regular catheter changes every 4-6 weeks help prevent biofilm formation. Funguria often recurs in patients with indwelling catheters because the underlying risk factors persist, making prevention strategies crucial for long-term management. It is essential to note that the management of funguria should be guided by the patient's clinical presentation and the results of diagnostic tests, rather than relying solely on the presence of fungi in the urine 1. In general, the treatment of funguria should be individualized and based on the specific needs of the patient, taking into account factors such as the severity of symptoms, the presence of underlying medical conditions, and the risk of complications 1.

From the FDA Drug Label

Urinary tract infections and peritonitis: 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 management of funguria in a patient with a suprapubic tube may involve the use of fluconazole, with daily doses of 50 to 200 mg.

• The treatment should be continued until clinical parameters or laboratory tests indicate that active fungal infection has subsided.
• It is essential to note that an inadequate period of treatment may lead to recurrence of active infection. 2

From the Research

Management of Funguria in Patients with Suprapubic Tubes

To manage funguria in patients with suprapubic tubes, several strategies can be employed:

• Removing unnecessary antibacterials and changing or removing indwelling urinary catheters may be beneficial, but are often inadequate without additional pharmacologic therapy 3.
• Bladder irrigations with amphotericin B have been used for many years, but the optimal concentration and method of irrigation are still debated 3.
• Intravesical amphotericin B and oral fluconazole therapy are each effective in clearing funguria, with amphotericin B acting more rapidly, but fluconazole having a more lasting effect 3.
• Fluconazole irrigation can be used to treat catheter-associated candiduria, and has been shown to be effective and safe in patients with suprapubic catheters 4.
• Amphotericin B bladder irrigations (ABBI) can be considered an alternative to fluconazole for the treatment of candiduria, and may be preferred over fluconazole in patients with renal dysfunction 5.

Treatment Options

The following treatment options are available for managing funguria in patients with suprapubic tubes:

• Oral fluconazole therapy
• Intravesical amphotericin B therapy
• Bladder irrigations with amphotericin B
• Fluconazole irrigation
• ABBI

Considerations

When managing funguria in patients with suprapubic tubes, the following considerations should be taken into account:

• The risk of candidemia, a serious complication of untreated asymptomatic funguria 3.
• The need for patient education on the importance of proper catheter care and management 6.
• The potential for renal dysfunction to affect treatment outcomes, with ABBI potentially being preferred over fluconazole in these cases 5.