Should Candida (fungus) in urine be treated?

From the Guidelines

Candiduria (Candida in urine) should only be treated in specific clinical scenarios, not routinely, as it often represents colonization rather than infection. The decision to treat should be based on patient risk factors and clinical presentation, prioritizing those at high risk for dissemination, such as neutropenic patients, very low-birth-weight infants, and patients undergoing urologic procedures 1.

Key Considerations

• Asymptomatic candiduria in patients with indwelling catheters often resolves with catheter removal alone and doesn't require antifungal therapy 1.
• Treatment is recommended for symptomatic patients, those undergoing urologic procedures, neutropenic patients, transplant recipients, and patients with high risk for disseminated infection 1.
• For treatment, oral fluconazole 200-400mg daily for 7-14 days is a suitable option due to its excellent urinary penetration, although the specific dosage might vary based on the clinical context, such as 400 mg (6 mg/kg) daily for patients undergoing urologic procedures 1.
• Alternative options include amphotericin B bladder irrigation for localized infections or IV echinocandins for systemic infections.

Clinical Approach

• Unnecessary treatment can lead to antifungal resistance and side effects without clinical benefit, which is why targeted therapy based on patient risk factors and clinical presentation is preferred over universal treatment 1.
• The presence of candiduria is often a marker for greater mortality but death is not related to Candida infection, and treatment for Candida infection does not change mortality rates 1.
• Conditions requiring an aggressive approach to candiduria in asymptomatic patients include neonates with very low birth weight and certain cases of neutropenic patients 1.

From the FDA Drug Label

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. 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.

Treatment of Candida in urine is recommended. The dosage for treatment of Candida urinary tract infections is 50 to 200 mg daily, as indicated in the studies 2 and 2.

From the Research

Treatment of Candida in Urine

• The presence of Candida species in urine in asymptomatic patients does not warrant antifungal therapy, except in cases of neutropenic patients, very low-birth-weight infants, and patients undergoing urologic procedures 3.
• Fluconazole is the treatment of choice for symptomatic infections, as it achieves high urinary levels 3, 4, 5.
• Other azole antifungals and echinocandins do not reach sufficient urine levels to be effective in treating Candida urinary tract infections 3, 4.
• Amphotericin B deoxycholate is an alternative antifungal agent if fluconazole cannot be used due to resistance, allergy, or failure 3.
• Removing predisposing factors, such as indwelling catheters and antibiotics, can clear candiduria in almost 50% of asymptomatic patients 4.
• Micafungin administration has been associated with both short- and long-term urine sterilization in hospitalized patients with candiduria 6.

Patient Risk Factors

• Diabetes mellitus, indwelling urinary catheters, use of broad-spectrum antibiotics, urinary obstruction, and admission to intensive care units are major risk factors for Candida urinary tract infections 3.
• Immunocompromised patients and those with Foley catheters are also at increased risk 6.
• Patients with candiduria may be asymptomatic or may develop symptomatic infections, such as cystitis, pyelonephritis, prostatitis, epididymo-orchitis, or disseminated candidiasis 3, 7.

Treatment Outcomes

• Fluconazole has been shown to be efficacious and safe in the treatment of urinary candidiasis, with eradication of the fungus in 88% of patients 5.
• Micafungin administration has been associated with urine sterilization rates of 81%, 78%, and 75% during treatment, 2 weeks after treatment, and more than 1 month after treatment, respectively 6.