What is the treatment for a patient with yeast in their urinalysis (UA)?

Management of Yeast in Urinalysis

For asymptomatic patients with yeast in urinalysis, treatment is not recommended unless the patient belongs to a high-risk group for dissemination. 1

Evaluation and Initial Management

• First determine if the finding represents contamination, colonization, or true infection:

  • Confirm with a second urine sample to rule out contamination
  • Assess for symptoms (dysuria, frequency, urgency, suprapubic pain)
  • Evaluate for risk factors:
    • Indwelling catheter
    • Recent antibiotics
    • Diabetes mellitus
    • Immunosuppression
    • Urologic abnormalities or instrumentation

• Remove predisposing factors:

  • Discontinue unnecessary antibiotics
  • Remove indwelling catheters if feasible (this alone resolves candiduria in ~50% of cases) 1, 2
  • Optimize management of diabetes if present

Treatment Algorithm Based on Clinical Presentation

1. Asymptomatic Candiduria

• No treatment needed for most patients without risk factors 1
• For high-risk patients (neutropenic, low birth weight infants, pre-urologic procedure):
  • Fluconazole 200-400 mg (3-6 mg/kg) daily for several days 1
  • Alternative: AmB deoxycholate 0.3-0.6 mg/kg daily for several days 1

2. Symptomatic Candida Cystitis

• For fluconazole-susceptible organisms (including C. albicans):

  • Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks 1

• For fluconazole-resistant C. glabrata:

  • AmB deoxycholate 0.3-0.6 mg/kg daily for 1-7 days OR
  • Oral flucytosine 25 mg/kg 4 times daily for 7-10 days 1

• For C. krusei:

  • AmB deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1

3. Candida Pyelonephritis

• For fluconazole-susceptible organisms:

  • Oral fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks 1

• For fluconazole-resistant C. glabrata:

  • AmB deoxycholate 0.3-0.6 mg/kg daily with or without flucytosine 25 mg/kg 4 times daily for 2 weeks OR
  • Monotherapy with flucytosine 25 mg/kg 4 times daily for 2 weeks 1

4. Fungus Balls

• Surgical intervention is strongly recommended in adults 1
• Systemic antifungal therapy as noted above for cystitis or pyelonephritis
• If access to collecting system is available, consider irrigation with AmB deoxycholate (50 mg/L sterile water) 1

Important Clinical Considerations

• Fluconazole is the preferred agent for most urinary Candida infections because:

  • It achieves high urine concentrations in its active form
  • It's available as an oral formulation
  • It's effective against most Candida species, especially C. albicans 1, 3

• Echinocandins and newer azoles (voriconazole, posaconazole) are NOT recommended for urinary tract infections as they achieve poor urinary concentrations 1, 2

• Lipid formulations of amphotericin B should NOT be used for urinary tract infections due to inadequate urine concentrations 1

• Treatment duration should continue until symptoms resolve and urine cultures no longer yield Candida species 1

• For patients with suspected disseminated candidiasis, treat as for candidemia with appropriate systemic therapy 1

Common Pitfalls to Avoid

1. Treating all patients with candiduria - most are colonized and don't require antifungal therapy
2. Using echinocandins or lipid formulations of amphotericin B for urinary tract infections
3. Failing to remove predisposing factors like catheters or unnecessary antibiotics
4. Not distinguishing between upper and lower tract infection
5. Overlooking the possibility of fungus ball formation in patients with persistent candiduria
6. Not considering species-specific resistance patterns when selecting therapy