What is the treatment for a patient with pyuria (Presence of 50+ White Blood Cells), hematuria (Presence of 30+ Red Blood Cells), candiduria (Yeast present), and glycosuria (+3 glucose)?

From the Guidelines

The treatment for a patient with pyuria, hematuria, candiduria, and glycosuria requires prompt medical attention with an empiric antibiotic and antifungal therapy, as well as management of the underlying diabetes. The patient's symptoms suggest a urinary tract infection with possible fungal involvement and uncontrolled diabetes.

• An empiric antibiotic such as nitrofurantoin (Macrobid) 100mg twice daily for 7 days or trimethoprim-sulfamethoxazole (Bactrim DS) one tablet twice daily for 7 days should be started immediately, as recommended by general urinary tract infection treatment guidelines.
• For the yeast infection component, fluconazole 200mg daily for 2 weeks is recommended, as it is the drug of choice for treating Candida UTI, according to the 2016 update by the Infectious Diseases Society of America 1.
• The high glucose level (+3) strongly suggests diabetes that needs management, typically starting with metformin 500mg twice daily with meals if newly diagnosed.
• A urine culture should be collected before starting antibiotics to identify the specific bacteria and determine antibiotic sensitivity.
• Increased fluid intake of 2-3 liters daily will help flush the urinary system.
• The presence of both high WBCs and RBCs indicates inflammation and possible tissue damage in the urinary tract, while yeast suggests either vaginal contamination or a fungal UTI, which is more common in diabetic patients due to the glucose-rich environment that promotes fungal growth.
• Blood glucose levels should be monitored regularly, and follow-up urinalysis should be performed after completing the antibiotic course to ensure resolution. It is essential to note that the 2016 guidelines 1 provide more recent and comprehensive recommendations for the management of candidiasis, including Candida UTI, compared to the 2009 guidelines 1. Therefore, the treatment plan should be based on the more recent guidelines.

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 a patient with candiduria (yeast present) may include fluconazole at a daily dose of 50 to 200 mg. However, the presence of pyuria (50+ White Blood Cells) and hematuria (30+ Red Blood Cells) suggests a possible bacterial infection, and glycosuria (+3 glucose) may indicate an underlying condition such as diabetes. The FDA drug label for fluconazole does not provide guidance on the treatment of these conditions. Therefore, the treatment for the patient's overall condition is not fully addressed by the fluconazole drug label 2.

From the Research

Treatment for Urinary Tract Infection

The patient's symptoms, including pyuria (Presence of 50+ White Blood Cells), hematuria (Presence of 30+ Red Blood Cells), candiduria (Yeast present), and glycosuria (+3 glucose), suggest a complicated urinary tract infection (UTI).

• The treatment for UTIs caused by antibiotic-resistant Gram-negative bacteria, such as those producing extended-spectrum beta-lactamases (ESBLs), includes fosfomycin, nitrofurantion, fluoroquinolones, cefepime, piperacillin-tazobactam, and carbapenems 3.
• For patients with ESBL-producing Enterobacteriaceae, alternatives to carbapenems may be used to treat mild-moderate UTIs, including ceftazidime-avibactam, colistin, polymixin B, fosfomycin, aztreonam, aminoglycosides, and tigecycline 3.
• High-dose amoxicillin with clavulanic acid has been shown to be effective in treating UTIs caused by ESBL-producing Klebsiella pneumoniae, with no therapeutic failures or recurrences observed in a study of 9 patients 4.
• Ciprofloxacin is considered a standard treatment for complicated UTIs, but its use should be restricted due to increasing rates of resistance; a once-daily regimen of 500 mg may be less effective than a twice-daily regimen of 250 mg 5.

Considerations for Treatment

• Urine culture with antimicrobial susceptibility testing should be performed to direct therapy, and imaging, blood cultures, and measurement of serum inflammatory markers should not be performed in uncomplicated cases 6.
• Prior positive urine cultures can be useful in predicting the identity and susceptibility of a current positive urine culture, and ciprofloxacin can be used empirically when prior urine culture results indicate a ciprofloxacin-susceptible organism and there has been no history of intervening fluoroquinolone use 7.
• The treatment should be chosen based on the severity of the infection, the patient's medical history, and local antimicrobial resistance patterns.
• It is essential to note that the presence of candiduria (yeast in the urine) may require antifungal treatment, and glycosuria (glucose in the urine) may indicate an underlying condition such as diabetes that requires separate management.