What is the treatment for Candida (a type of fungal infection) in the urine?

Treatment of Candida in Urine

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

Diagnostic Approach

Before initiating treatment, it's crucial to determine whether candiduria represents:

• Contamination
• Asymptomatic colonization
• Symptomatic infection (cystitis or pyelonephritis)

Key considerations:

• Repeat urine culture to confirm persistent candiduria
• Assess for symptoms (dysuria, frequency, urgency, flank pain)
• Evaluate for risk factors (catheterization, antibiotics, diabetes, immunosuppression)

Treatment Algorithm

1. Asymptomatic Candiduria

• No treatment is generally recommended 2
• Remove predisposing factors (especially indwelling catheters) which resolves candiduria in ~40% of cases 2
• Exceptions requiring treatment despite being asymptomatic:
  • Neutropenic patients
  • Very low birth weight neonates
  • Patients undergoing urologic procedures (treat with fluconazole before and after)

2. Symptomatic Candida Cystitis

• First-line: Fluconazole 200 mg (3 mg/kg) daily for 2 weeks 2
• 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 2
• For C. krusei: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 2
• Remove indwelling bladder catheter if present (strongly recommended) 2

3. Candida Pyelonephritis

• First-line: Fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks 2
• For fluconazole-resistant strains:
  • Amphotericin B deoxycholate 0.5-0.7 mg/kg daily with or without flucytosine 2
  • Monotherapy with oral flucytosine 25 mg/kg 4 times daily for 2 weeks (alternative) 2
• Eliminate any urinary tract obstruction 2
• Consider removal/replacement of nephrostomy tubes or stents 2

4. Fungus Balls

• Surgical intervention is strongly recommended 2
• Systemic antifungal therapy with fluconazole 200-400 mg daily 2
• If access to renal collecting system is available, consider irrigation with amphotericin B (50 mg/L sterile water) 2
• Continue treatment until symptoms resolve and cultures are negative 2

Important Considerations

1. Medications to avoid:

   • Echinocandins (caspofungin, micafungin, anidulafungin) due to minimal urinary excretion 1
   • Lipid formulations of amphotericin B have poor urinary concentrations 1
   • Voriconazole and other azoles (except fluconazole) have poor urinary concentrations 1

2. Catheter management:

   • Removal of indwelling catheters alone may resolve candiduria in up to 40% of cases 2
   • For patients requiring continued catheterization, change the catheter when starting antifungal therapy

3. Follow-up:

   • Obtain follow-up urine cultures to document clearance
   • Continue treatment until symptoms resolve and cultures are negative

Pitfalls to Avoid

1. Treating all candiduria: Most asymptomatic candiduria represents colonization and does not require treatment 3, 4

2. Failing to identify the Candida species: C. glabrata and C. krusei may be fluconazole-resistant and require alternative therapy 2

3. Using echinocandins for urinary tract infections: These drugs achieve poor urinary concentrations and are not recommended 3

4. Overlooking underlying conditions: Correct predisposing factors such as obstruction, stones, or foreign bodies 2

5. Inadequate duration of therapy: Premature discontinuation may lead to recurrence; continue treatment for at least 2 weeks 1