Duration of Therapy for Candida UTI
For Candida urinary tract infections, the recommended treatment duration is 14 days for both symptomatic cystitis and pyelonephritis. 1
Treatment Approach Based on Type of Infection
Asymptomatic Candiduria
- Treatment is generally NOT recommended unless the patient belongs to a high-risk group 1
- High-risk groups requiring treatment include:
- Neutropenic patients
- Very low-birth-weight infants (<1500g)
- Patients undergoing urologic manipulation/procedures 1
- For patients undergoing urologic procedures: oral fluconazole 400 mg daily for several days before and after the procedure 1
Symptomatic Candida Cystitis
- First-line treatment: Oral fluconazole 200 mg (3 mg/kg) daily for 14 days for fluconazole-susceptible organisms 1
- For fluconazole-resistant C. glabrata:
- Amphotericin B 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: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1
- Removal of indwelling bladder catheter if present (strongly recommended) 1
- Amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) may be useful for fluconazole-resistant species 1, 2
Candida Pyelonephritis
- First-line treatment: Oral fluconazole 200-400 mg (3-6 mg/kg) daily for 14 days for fluconazole-susceptible organisms 1
- For fluconazole-resistant C. glabrata:
- Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days with or without flucytosine, OR
- Monotherapy with oral flucytosine 25 mg/kg 4 times daily for 14 days 1
- For C. krusei: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1
- Elimination of urinary tract obstruction is strongly recommended 1
- Consider removal or replacement of nephrostomy tubes or stents if present 1
Fungus Balls or Obstructive Lesions
- Surgical 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
Important Clinical Considerations
Diagnostic Confirmation
- Confirm true infection versus contamination with repeat urine culture 3
- Distinguish between asymptomatic colonization and symptomatic infection 4
Medication Selection Factors
- Fluconazole is preferred due to:
- High urine concentrations
- Availability in both oral and IV formulations
- Good safety profile 4
- Echinocandins and newer azoles (voriconazole, posaconazole) are NOT recommended for urinary tract infections as they fail to achieve adequate urine concentrations 5
Catheter Management
- Removing indwelling catheters will clear candiduria in almost 50% of asymptomatic patients 5
- Catheter removal or replacement should be the first step in management 3
Monitoring
- Follow-up urine cultures to document clearance 2
- Monitor renal function when using amphotericin B formulations 2
- Assess for clinical improvement of symptoms 2
Pitfalls and Caveats
- Most candiduria represents colonization rather than infection and does not require treatment 4
- Distinguishing between colonization and true infection is critical to avoid unnecessary antifungal use
- For fluconazole-resistant species, treatment options are more limited and may require longer courses of amphotericin B or combination therapy
- Always consider removing predisposing factors (catheters, antibiotics) as this alone may resolve candiduria in many cases