What is the next step for an 85-year-old febrile man with a chronic suprapubic (urinary catheter inserted through the lower abdomen) tube and persistent candiduria (fungal infection of the urine) after suprapubic tube change?

From the Guidelines

The next step for an 85-year-old febrile man with a chronic suprapubic tube and persistent candiduria after tube change is to initiate antifungal therapy with oral fluconazole 400 mg on day 1, followed by 200 mg daily for 14 days. This treatment is necessary because the presence of fever along with candiduria in a catheterized elderly patient suggests an invasive fungal urinary tract infection rather than simple colonization, as suggested by 1. The suprapubic tube provides a direct portal for organisms to ascend into the bladder, and the patient's advanced age further increases his risk for complications.

Key Considerations

• Fluconazole is preferred because it achieves high urinary concentrations and is effective against most Candida species, as recommended by 1 and 1.
• During treatment, ensure adequate hydration to maintain good urine flow, monitor renal function as fluconazole dosing may need adjustment in renal impairment, and evaluate for clinical improvement within 48-72 hours.
• If the patient fails to respond to fluconazole or if cultures show resistant Candida species like C. glabrata or C. krusei, alternative antifungals such as amphotericin B bladder irrigation or systemic echinocandins may be necessary, as suggested by 1.

Treatment Approach

• The treatment approach should prioritize the patient's quality of life, morbidity, and mortality, and should be guided by the most recent and highest quality evidence, which in this case is 1.
• The patient's advanced age and presence of a chronic suprapubic tube increase his risk for complications, and therefore require prompt and effective treatment.
• The treatment should be tailored to the patient's specific needs and circumstances, taking into account his renal function, overall health, and potential interactions with other medications.

From the Research

Next Steps for Treatment

The patient has a chronic suprapubic tube and persistent candiduria after the tube change. Considering the patient's symptoms, the next steps for treatment are:

• Evaluate the patient's clinical status to determine the appropriate therapy 2, 3, 4
• Consider removing predisposing factors, such as antibiotics, and assess the need for antifungal therapy 3
• For symptomatic Candida urinary tract infections, fluconazole is the antifungal agent of choice, achieving high urine concentrations with the oral formulation 2, 3, 4
• Alternative antifungal agents, such as amphotericin B, may be considered if fluconazole cannot be used due to resistance, allergy, or failure 2

Treatment Options

Treatment options for the patient include:

• Fluconazole therapy, which is preferred for the treatment of Candida UTIs due to its safety, achievement of high concentrations in the urine, and availability in both oral and intravenous formulations 2, 3, 4
• Irrigation of the bladder with antifungal agents, such as fluconazole, which has been shown to be effective and safe in the treatment of catheter-associated candiduria 5
• Amphotericin B therapy, which may be useful for Candida UTIs in selected patients, particularly those with fungus balls or systemic candidiasis 4, 6

Considerations

When determining the appropriate therapy, consider the following:

• The patient's clinical status and the site of infection 4
• The pharmacokinetics and pharmacodynamics of the antifungal agent 4
• The potential for toxicity and side effects associated with antifungal therapy 4, 6