From the Guidelines
The treatment of fungal cystitis typically involves antifungal medications, with fluconazole being the first-line therapy, at a dosage of 200 mg (3 mg/kg) daily for 2 weeks, as recommended by the most recent guidelines 1. The choice of antifungal medication depends on the susceptibility of the Candida species to fluconazole.
- For fluconazole-susceptible organisms, oral fluconazole is the recommended treatment 1.
- For fluconazole-resistant organisms, such as C. glabrata, alternatives include AmB deoxycholate at a dosage of 0.3–0.6 mg/kg daily for 1–7 days or oral flucytosine at a dosage of 25 mg/kg 4 times daily for 7–10 days 1. Some important considerations in the treatment of fungal cystitis include:
- Removal of an indwelling bladder catheter, if feasible, is strongly recommended 1.
- AmB deoxycholate bladder irrigation, 50 mg/L sterile water daily for 5 days, may be useful for treatment of cystitis due to fluconazole-resistant species, such as C. glabrata and C. krusei 1. It is essential to address underlying conditions that predispose to fungal infections, such as diabetes, immunosuppression, or indwelling catheters, and to identify and remove risk factors such as unnecessary antibiotics or catheters 1. Follow-up urine cultures are crucial to confirm eradication of the infection 1.
From the FDA Drug Label
Urinary tract infections and peritonitis: 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. The treatment for fungal cystitis, specifically Candida urinary tract infections, is fluconazole with daily doses of 50 to 200 mg 2.
From the Research
Treatment of Fungal Cystitis
The treatment of fungal cystitis, particularly those caused by Candida species, involves several key considerations:
- 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, 4, 5.
- Fluconazole is the treatment of choice for symptomatic infections, as it achieves high urinary levels 3, 4, 5, 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.
- Amphotericin B deoxycholate is an alternative antifungal agent if fluconazole cannot be used due to resistance, allergy, or failure 3, 7.
- Other azole antifungals and echinocandins are not recommended for the treatment of urinary tract infections, as they fail to achieve adequate urine concentrations 3, 5.
- Removing predisposing factors, such as indwelling catheters and antibiotics, can clear candiduria in almost 50% of asymptomatic patients 5.
- Treatment decisions are driven by an understanding of the anatomic site of infection, with Candida cystitis typically requiring fluconazole treatment, and ascending pyelonephritis requiring the administration of a systemic antifungal agent and often requiring correction of the obstruction or surgical drainage 4.