What is the treatment for symptomatic urinary tract infections (UTIs) caused by Candida?

Treatment of Symptomatic Candida Urinary Tract Infections

For symptomatic Candida UTIs, fluconazole 200 mg daily for 2 weeks is the first-line treatment due to its excellent urinary penetration and efficacy against most Candida species. 1, 2

First-Line Treatment

• Fluconazole: 200-400 mg (3-6 mg/kg) daily for 2 weeks 1
  • Achieves high urinary concentrations
  • FDA-approved for Candida urinary tract infections 3
  • Most effective against C. albicans and many non-albicans species
  • Some clinicians recommend a 200 mg loading dose followed by 100 mg daily for at least 4 days 4

Alternative Treatments (for fluconazole-resistant species or treatment failures)

• Amphotericin B deoxycholate: 0.3-0.6 mg/kg daily for 1-7 days 1
  • Achieves adequate urinary concentrations
  • Significant nephrotoxicity limits use
• Flucytosine: 25 mg/kg four times daily for 7-10 days 1
  • Good urinary concentrations
  • Limited by toxicity and rapid development of resistance when used alone
  • Often combined with amphotericin B for synergistic effect

Special Considerations

Candida Species

• C. albicans: Usually fluconazole-susceptible
• C. glabrata and C. krusei: Often fluconazole-resistant, may require alternative therapy 1

Anatomical Location

1. Cystitis (bladder infection):

   • Fluconazole 200 mg daily for 2 weeks 1

2. Pyelonephritis (kidney infection):

   • Fluconazole 200-400 mg daily for 2 weeks 1
   • Alternative: Amphotericin B deoxycholate 0.5-0.7 mg/kg daily with or without flucytosine 1

3. Fungus balls:

   • Surgical removal is strongly recommended 1
   • Adjunctive antifungal therapy with fluconazole or amphotericin B 1
   • Local irrigation with amphotericin B (50 mg/L sterile water) may be useful 1

Important Management Steps

• Remove indwelling urinary catheters if present 1
  • Catheter removal alone resolves candiduria in many patients
• Correct any underlying urinary tract obstruction 2
• Discontinue unnecessary antibiotics 5
• Treat until symptoms have resolved and urine cultures no longer yield Candida species 1

Ineffective Treatments to Avoid

• Echinocandins (caspofungin, micafungin, anidulafungin): Minimal urinary excretion makes them ineffective for UTIs limited to the urinary tract 1, 2, 5
  • Exception: May be considered for pyelonephritis with concurrent candidemia 1
• Lipid formulations of amphotericin B: Poor urinary concentrations 1
• Voriconazole and other azoles (except fluconazole): Minimal urinary excretion 2, 5

Follow-up

• Obtain follow-up urine cultures to document clearance
• Monitor for symptom resolution
• For recurrent infections, evaluate for structural abnormalities or immunosuppression

Pitfalls to Avoid

• Don't treat asymptomatic candiduria (except in high-risk patients like neutropenic adults or those undergoing urologic procedures) 1, 6
• Don't rely on colony counts alone to diagnose infection versus colonization 1
• Don't use echinocandins or newer azoles as first-line agents due to poor urinary concentrations 5
• Don't forget to remove indwelling catheters when possible 1

By following these evidence-based recommendations, most symptomatic Candida UTIs can be effectively treated with good clinical outcomes.