What is the next step in managing an 85-year-old febrile man with persistent funguria (greater than 10^5 colony-forming units per ml of Candida) on urine culture after changing the suprapubic (SP) tube?

Management of Persistent Funguria in an 85-Year-Old Febrile Man with Suprapubic Tube

For an 85-year-old febrile man with persistent Candida funguria (>10^5 CFU/mL) despite suprapubic tube change, the next step is to initiate oral fluconazole 200-400 mg daily for 2 weeks. 1

Assessment and Classification

This case represents symptomatic funguria (presence of fever) in a patient with a urinary catheter (suprapubic tube) and persistent fungal colonization despite catheter change. Key considerations:

• Fever in the setting of candiduria suggests possible symptomatic infection rather than mere colonization
• Persistence after tube change indicates established infection requiring systemic treatment
• Age (85) and presence of indwelling catheter are significant risk factors

Treatment Algorithm

1. First-Line Therapy

• Fluconazole 200-400 mg (3-6 mg/kg) orally daily for 2 weeks 1
• This is the drug of choice for most Candida urinary tract infections as it:
  • Achieves high urinary concentrations
  • Is excreted in active form in urine
  • Has demonstrated efficacy in controlled trials 1

2. Alternative Therapy (if fluconazole-resistant Candida suspected)

• If C. glabrata or C. krusei is identified (fluconazole-resistant species):
  • Amphotericin B deoxycholate 0.3-0.6 mg/kg IV daily for 1-7 days 1
  • Consider adding flucytosine 25 mg/kg orally four times daily 1

3. Adjunctive Measures

• Attempt removal or replacement of suprapubic tube if clinically feasible 1
• Evaluate for urinary tract obstruction and relieve if present 1
• Assess for fungus balls or other obstructive lesions with imaging 1

Special Considerations

Catheter Management

• Catheter removal/replacement alone resolves candiduria in approximately 40% of cases 1
• Since the suprapubic tube has already been changed without resolution, systemic therapy is warranted

Monitoring Response

• Follow-up urine cultures to document clearance
• Monitor for clinical improvement (resolution of fever)
• Assess renal function if using amphotericin B

Potential Complications

• Evaluate for signs of disseminated candidiasis, particularly in a febrile elderly patient
• Consider blood cultures if fever persists despite appropriate therapy

Evidence Quality and Considerations

The recommendation for fluconazole is supported by strong evidence from the Infectious Diseases Society of America guidelines 1. These guidelines specifically address the management of candiduria in patients with urinary catheters and provide clear treatment recommendations based on clinical presentation.

While some studies suggest amphotericin B bladder irrigation may be effective 2, this approach is generally discouraged except for refractory cases with fluconazole-resistant organisms 1. Systemic therapy is preferred in this case due to the presence of fever, suggesting possible upper tract involvement or systemic infection.