What is the recommended treatment for symptomatic candiduria?

From the Guidelines

The recommended treatment for symptomatic candiduria is oral fluconazole at a dosage of 200 mg daily for 2 weeks, as it achieves high urinary concentrations and has good activity against most Candida species. For patients who cannot tolerate oral medications, alternative options include amphotericin B bladder irrigation or oral flucytosine 1. Before initiating treatment, it's essential to remove or replace any urinary catheters if present, as they often serve as a nidus for infection. Treating underlying conditions that predispose to candiduria, such as diabetes or immunosuppression, is also crucial. Asymptomatic candiduria generally doesn't require treatment except in high-risk patients like neutropenic individuals or those undergoing urologic procedures.

• Key considerations in the treatment of symptomatic candiduria include:
  • The use of fluconazole as the first-line treatment due to its efficacy and high urinary concentrations 1
  • The potential for resistance with C. glabrata or C. krusei, which may require alternative antifungals such as amphotericin B or flucytosine 1
  • The importance of removing or replacing urinary catheters to prevent recurrence of infection 1
  • The need to treat underlying conditions that predispose to candiduria, such as diabetes or immunosuppression 1
• In cases of fluconazole-resistant organisms, alternatives include amphotericin B 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.
• For patients with pyelonephritis due to fluconazole-susceptible organisms, oral fluconazole at a dosage of 200–400 mg daily for 2 weeks is recommended 1.
• Fungus balls require aggressive surgical debridement and systemic treatment with amphotericin B or fluconazole, with possible adjunctive local irrigation with amphotericin B 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.

The recommended treatment for symptomatic candiduria is a daily dose of 50 to 200 mg of fluconazole, as used in open, noncomparative studies of small numbers of patients 2.

• The dosage may vary based on the patient's response to therapy and renal function.
• Patients with impaired renal function may require dose adjustments.
• The treatment duration is not explicitly stated for candiduria, but it is generally recommended to continue treatment until clinical parameters or laboratory tests indicate that active fungal infection has subsided.

From the Research

Treatment of Symptomatic Candiduria

The recommended treatment for symptomatic candiduria is a topic of ongoing research and debate.

• The treatment options for symptomatic candiduria include fluconazole, amphotericin B-based products, and flucytosine 3.
• However, the choice of treatment depends on the species of Candida, with some species exhibiting intrinsic resistance to certain antifungals 4.
• Echinocandins, such as micafungin and caspofungin, have been shown to be effective in treating symptomatic candiduria, despite their poor urinary concentrations 4, 5.
• The Infectious Diseases Society of America (IDSA) guidelines recommend the use of antifungal therapy for symptomatic candiduria, but the choice of antifungal and duration of treatment are not well defined 6, 7.

Factors Affecting Treatment Decisions

Several factors can affect treatment decisions for symptomatic candiduria, including:

• The species of Candida isolated from the urine 4
• The presence of underlying medical conditions, such as immunocompromised state or renal failure 3, 5
• The presence of an indwelling bladder catheter 5
• The severity of symptoms and the clinical presentation of the patient 7

Current Practice and Guidelines

Despite the availability of guidelines, the management of candiduria in hospitalized patients is often inappropriate, with overtreatment of asymptomatic candiduria and improper drug selection for symptomatic patients being common 6, 7.

• The IDSA guidelines recommend the elimination of predisposing factors, such as indwelling catheters, and the use of antifungal therapy for symptomatic candiduria 6, 7.
• However, the significance of these guidelines and the optimal management of candiduria require further clarification in future multicenter investigations 7.