What is the next step in managing an 85-year-old man with a cystostomy tube and persistent Candida positive urine culture without fever?

From the Guidelines

For an 85-year-old man with a cystostomy tube and persistent Candida in urine without fever, the next step is to observe without antifungal treatment. Asymptomatic candiduria in patients with indwelling urinary catheters generally does not require treatment, as it represents colonization rather than infection 1. The presence of Candida in urine without symptoms like fever, pain, or systemic illness is common in elderly patients with long-term catheters and typically resolves spontaneously or with catheter change.

Key Considerations

• The patient's age and lack of symptoms suggest that treatment may not be necessary, and the risk of promoting resistance or causing side effects with antifungal therapy should be considered 1.
• Regular catheter care and hygiene should be maintained, including periodic changes of the cystostomy tube according to the established schedule.
• If treatment becomes necessary due to symptoms developing, fluconazole 200 mg orally on day 1 followed by 100 mg daily for 7-14 days would be appropriate for most Candida species, as it achieves high concentrations in the urine and is effective against Candida albicans, the most common cause of fungal UTI 1.

Rationale for Withholding Treatment

• Unnecessary antifungals can promote resistance and cause side effects in elderly patients 1.
• Treating simple colonization rather than true infection provides no clinical benefit 1.

Additional Considerations

• Imaging of the urinary tract by ultrasound or CT scanning may be helpful in defining structural abnormalities, hydronephrosis, abscesses, emphysematous pyelonephritis, and fungus ball formation, but is not necessary in this case without symptoms 1.
• Other antifungal drugs, including the other azole agents and echinocandins, have minimal excretion of active drug into the urine and generally are ineffective in treating Candida UTI, and should not be used as first-line treatment 1.

From the FDA Drug Label

Fluconazole tablets are indicated for the treatment of: ... Oropharyngeal and esophageal candidiasis ... 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.

The next step in managing an 85-year-old man with a cystostomy tube and persistent Candida positive urine culture without fever is to consider antifungal treatment.

• Fluconazole is an option for the treatment of Candida urinary tract infections 2. Given the patient's age and the presence of a cystostomy tube, it is essential to weigh the benefits and risks of treatment and monitor the patient closely for any adverse effects. However, the FDA label does not provide specific guidance on the management of asymptomatic Candida colonization in the urine, and the decision to treat should be based on clinical judgment and individual patient factors.

From the Research

Management of Candida Urinary Tract Infection

The patient in question is an 85-year-old man with a cystostomy tube and a positive Candida urine culture, but without fever. The culture remains positive after the tube is changed.

• The presence of Candida species in urine in asymptomatic patients does not warrant antifungal therapy, except in certain cases such as neutropenic patients, very low-birth-weight infants, and patients undergoing urologic procedures 3, 4.
• Since the patient is asymptomatic and does not have fever, the first step would be to remove any predisposing factors, such as the indwelling catheter, if possible, and to manage any underlying conditions that may be contributing to the infection 4.
• If the patient remains asymptomatic, no antifungal therapy may be necessary, as removing predisposing factors can clear candiduria in almost 50% of asymptomatic patients 4.
• However, if antifungal therapy is deemed necessary due to the patient's clinical status or failure to clear the infection after removing predisposing factors, fluconazole is the treatment of choice for symptomatic infections, achieving high urinary levels 3, 5, 4, 6.
• The recommended dose of fluconazole for the treatment of symptomatic fungal urinary tract infection is a 200-mg loading dose followed by 100 mg/d for at least four days 6.

Considerations for Treatment

• Other azole antifungals and echinocandins are not recommended for the treatment of urinary tract infections since they fail to achieve adequate urine concentrations 3, 5, 4.
• Amphotericin B deoxycholate is an alternative antifungal agent if fluconazole cannot be used due to resistance, allergy, or failure 3.
• Irrigation of the bladder with antifungal agents has limited utility, but in cases of fungus balls, irrigation of the renal pelvis through a nephrostomy tube can be useful in combination with systemic antifungal agents 5, 7.