From the Guidelines
The next step for this 85-year-old man with a cystostomy tube and persistent Candida urinary tract infection despite tube change is to initiate antifungal therapy with fluconazole as the first-line treatment. The patient's persistent fever despite catheter change suggests that this is a true infection rather than colonization, which warrants treatment 1. Fluconazole is the recommended first-line treatment, typically starting with a loading dose of 800 mg followed by 400 mg daily for 2-4 weeks 1. If the patient has risk factors for fluconazole-resistant Candida species (such as prior fluconazole exposure), an echinocandin like caspofungin (70 mg loading dose, then 50 mg daily) or micafungin (100 mg daily) may be more appropriate 1.
Some key points to consider in the management of this patient include:
- Evaluating the patient for potential complications such as fungal balls, renal involvement, or systemic candidiasis through appropriate imaging studies and blood cultures 1
- Ensuring adequate hydration and considering urologic consultation for possible irrigation of the collecting system may be beneficial 1
- The underlying reason for treatment is that in elderly patients with indwelling urinary catheters, Candida infections can progress from simple colonization to symptomatic infection and potentially to systemic disease, especially when fever persists despite addressing the potential source of infection 1
It's also important to note that the patient's age and the presence of an indwelling catheter increase the risk of complications and systemic disease, making prompt and effective treatment crucial 1. The treatment approach should be individualized based on the patient's specific clinical scenario, including the presence of any underlying medical conditions, previous antifungal therapy, and the results of diagnostic tests 1.
From the FDA Drug Label
In open noncomparative studies of relatively small numbers of patients, fluconazole tablets were also effective for the treatment of Candida urinary tract infections, peritonitis, and systemic Candida infections including candidemia, disseminated candidiasis, and pneumonia. In open noncomparative studies of relatively small numbers of patients, fluconazole was also effective for the treatment of Candida urinary tract infections, peritonitis, and systemic Candida infections including candidemia, disseminated candidiasis, and pneumonia
The next step for an 85-year-old man with a cystostomy tube and a positive urine culture for Candida, who remains febrile after tube change, is to consider antifungal therapy.
- Fluconazole (2, 3) may be an option for the treatment of Candida urinary tract infections.
- It is essential to obtain specimens for fungal culture and other relevant laboratory studies prior to therapy to isolate and identify causative organisms.
- Therapy may be instituted before the results of the cultures and other laboratory studies are known; however, once these results become available, anti-infective therapy should be adjusted accordingly.
From the Research
Next Steps for Treatment
The patient remains febrile with a positive urine culture for Candida after the cystostomy tube change. The following steps can be considered:
- Antifungal treatment: Fluconazole has been shown to be effective in treating candidal infections 4. Voriconazole is also an option, as it has been found to be non-inferior to amphotericin B followed by fluconazole in treating candidaemia in non-neutropenic patients 5.
- Assessment of the patient's underlying condition: The patient's age and underlying health conditions should be taken into account when selecting an antifungal agent.
- Monitoring for potential side effects: The patient should be monitored for potential side effects of antifungal treatment, such as renal toxicity or adverse events 5.
Treatment Options
The following antifungal agents can be considered for treatment:
- Fluconazole: Effective in treating candidal infections, especially in non-neutropenic patients 4, 5.
- Voriconazole: Non-inferior to amphotericin B followed by fluconazole in treating candidaemia in non-neutropenic patients 5.
- Echinocandins (e.g., caspofungin): Fungicidal against most Candida species, but may be less potent against certain species 6, 7.
- Amphotericin B: Can be used as an initial treatment, but may have more toxic effects compared to other options 5, 7.
Considerations for Antifungal Therapy
When selecting an antifungal agent, the following factors should be considered:
- Severity of the infection
- Comorbid conditions
- Candida species causing the infection
- Potential for resistance development 6