What is the treatment for Candida urinary tract infection (UTI)?

Treatment of Candida Urinary Tract Infections

For Candida UTIs, oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks is the first-line treatment for fluconazole-susceptible organisms, along with removal of any indwelling urinary catheters if present. 1

Treatment Algorithm Based on Candida Species

Fluconazole-Susceptible Candida (e.g., C. albicans)

• First-line: Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks 1
• Removal of indwelling catheter if present (resolves candiduria in ~50% of cases) 1, 2

Fluconazole-Resistant C. glabrata

• First-line: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1
• Alternative options:
  • Oral flucytosine 25 mg/kg 4 times daily for 7-10 days 1
  • Combination therapy with amphotericin B deoxycholate and flucytosine 1
  • Amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) for localized cystitis 1

C. krusei

• First-line: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1
• Amphotericin B bladder irrigation may be useful for localized cystitis 1

Special Considerations

Pyelonephritis

• Fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks for susceptible organisms 1
• For fluconazole-resistant organisms, use amphotericin B deoxycholate with or without flucytosine 1
• Elimination of urinary tract obstruction is essential 1

Fungus Balls

• Surgical or endoscopic intervention is strongly recommended 1
• Antifungal treatment as noted above for cystitis or pyelonephritis 1
• Irrigation through nephrostomy tubes (if present) with amphotericin B deoxycholate 25-50 mg in 200-500 mL sterile water 1

Asymptomatic Candiduria

• Treatment generally not recommended unless patient belongs to high-risk group 1, 2
• High-risk groups requiring treatment despite being asymptomatic:
  • Neutropenic patients
  • Very low birth-weight infants
  • Patients undergoing urologic procedures 1

Important Clinical Pearls

• Always remove or replace urinary catheters when possible, as this alone resolves candiduria in almost 50% of cases 1, 2
• Newer azole agents (other than fluconazole) and echinocandins are not recommended for urinary tract infections as they fail to achieve adequate urine concentrations 2, 3
• For patients undergoing urologic procedures with candiduria, treat with fluconazole 400 mg daily for several days before and after the procedure 1
• Fluconazole is particularly effective because it achieves high concentrations in the urine in its active form 1
• Imaging of the urinary tract (ultrasound or CT) should be considered to rule out structural abnormalities, hydronephrosis, abscesses, or fungus balls 1

Duration of Treatment

• For uncomplicated cystitis: 2 weeks 1
• For pyelonephritis: 2 weeks 1
• For fungus balls: Continue until complete resolution 1

The treatment of Candida UTIs requires consideration of both the infecting species and the location of infection within the urinary tract. Fluconazole remains the cornerstone of therapy for susceptible organisms, while amphotericin B formulations are crucial for resistant species. Addressing underlying factors such as catheters and obstructions is equally important for successful treatment outcomes.