What is the recommended fluconazole (fluconazole) dose and frequency for treating uncomplicated candiduria in patients with impaired renal function?

From the Guidelines

For patients with impaired renal function who have uncomplicated candiduria, the recommended fluconazole dose is 200 mg initially, followed by 100 mg daily, with adjustments for renal impairment, as stated in the 2016 update by the Infectious Diseases Society of America 1. The adjustment for renal impairment is crucial, as fluconazole is primarily eliminated through the kidneys.

• For patients with creatinine clearance less than 50 mL/min, the maintenance dose should be reduced by 50% (to 50 mg daily) to avoid potential toxicity.
• For patients on hemodialysis, a full dose should be administered after each dialysis session to ensure adequate drug levels. Key considerations in treating uncomplicated candiduria include:
• Treatment duration, typically 7-14 days, as recommended by the guidelines 1.
• Monitoring renal function during treatment, as fluconazole can affect kidney function.
• Confirming the diagnosis with a urine culture and assessing for complicating factors like obstruction or foreign bodies (such as catheters), which should be addressed if present, as emphasized in the guidelines 1.
• Identifying the specific Candida species to guide therapy, as some species like C. glabrata and C. krusei may have reduced susceptibility to fluconazole, as noted in the 2016 update 1. Adequate hydration should be maintained during treatment to help flush the urinary tract, promoting the elimination of the fungus and reducing the risk of recurrence. The most recent guidelines from 2016 1 provide the strongest evidence for managing candiduria, including recommendations for fluconazole dosing and adjustments for renal impairment.

From the FDA Drug Label

Dosage In Patients With Impaired Renal Function: Fluconazole is cleared primarily by renal excretion as unchanged drug. ... In patients with impaired renal function who will receive multiple doses of fluconazole tablets, an initial loading dose of 50 mg to 400 mg should be given After the loading dose, the daily dose (according to indication) should be based on the following table: Creatinine Clearance (mL/min) Recommended Dose (%)

50 100 ≤50 (no dialysis) 50 Hemodialysis 100% after each hemodialysis Patients on hemodialysis should receive 100% of the recommended dose after each hemodialysis; on non-dialysis days, patients should receive a reduced dose according to their creatinine clearance.

The recommended fluconazole dose and frequency for treating uncomplicated candiduria in patients with impaired renal function is not explicitly stated in the provided drug label. However, based on the dosage adjustments for patients with impaired renal function, the daily dose should be reduced according to the creatinine clearance.

• For patients with creatinine clearance >50 mL/min, the recommended dose is 100%.
• For patients with creatinine clearance ≤50 mL/min (no dialysis), the recommended dose is 50%.
• For patients on hemodialysis, the recommended dose is 100% after each hemodialysis, and a reduced dose on non-dialysis days according to their creatinine clearance. The specific dose and frequency for uncomplicated candiduria should be determined based on the patient's renal function and the table provided in the drug label 2.

From the Research

Fluconazole Dosing for Uncomplicated Candiduria with Impaired Renal Function

• The recommended fluconazole dose and frequency for treating uncomplicated candiduria in patients with impaired renal function is not directly stated in the provided studies, but some studies provide guidance on dosing adjustments for renal impairment 3, 4, 5.
• A study published in 2020 recommends doses of 400 mg for patients with poor to moderate renal function, 600 mg for patients with adequate renal function, and 800 mg for patients treated with CRRT 3.
• Another study from 1990 suggests that dosage reduction is advised for patients with impaired renal function, with once-daily doses of 100-400 mg recommended 4.
• A 1990 study assessing the effects of impaired renal function and haemodialysis on the pharmacokinetics of fluconazole found that fluconazole renal clearance was positively correlated with GFR, and non-renal clearance of fluconazole decreased with decreasing renal function 5.
• The study also found that approximately 38% of the 50 mg dose of fluconazole was removed by haemodialysis extending over a 3 h period 5.
• A 1993 drug usage evaluation found that many fluconazole-treated patients were receiving inappropriate dosages, with renal function not being taken into consideration in 30% of cases 6.

Considerations for Dosing Adjustments

• Renal function should be considered when determining the fluconazole dose, with adjustments made for impaired renal function 3, 4, 5.
• The type and severity of infection, identity of the causative organism, and response to therapy should also be taken into account when determining the fluconazole dose 6.
• Haemodialysis may affect fluconazole clearance, with approximately 38% of the dose removed during a 3 h period 5.

Alternative Treatment Options

• Amphotericin B bladder irrigations (ABBI) may be considered an alternative treatment option for candiduria, particularly in patients with renal dysfunction 7.