What is the treatment for candiduria (fungal infection of the urine)?

Treatment of Candiduria (Fungal Infection of the Urine)

For candiduria, treatment depends on whether the patient is symptomatic or asymptomatic, with fluconazole 200 mg daily for 2 weeks being the first-line treatment for symptomatic infections. 1, 2

Diagnostic Assessment

• Determine whether candiduria represents contamination, colonization, or true infection
• Repeat urine culture to confirm persistent candiduria
• Evaluate for risk factors: catheterization, antibiotics, diabetes, immunosuppression

Treatment Algorithm

Asymptomatic Candiduria

• No treatment recommended for most patients 1, 2
• Exceptions (high-risk patients requiring treatment):
  • Neutropenic patients
  • Very low birth weight neonates
  • Patients undergoing urologic procedures
    • For urologic procedures: Fluconazole 200-400 mg daily or amphotericin B deoxycholate 0.3-0.6 mg/kg daily for several days before and after the procedure 1

Symptomatic Candiduria

For Cystitis

• First-line: Fluconazole 200 mg (3 mg/kg) daily for 2 weeks 1, 2, 3
  • Excellent urinary penetration and efficacy against most Candida species
• For fluconazole-resistant organisms (especially 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, 2
  • Amphotericin B bladder irrigation may be useful for fluconazole-resistant species 1

For Pyelonephritis

• First-line: Fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks 1
• For fluconazole-resistant strains:
  • Amphotericin B deoxycholate 0.5-0.7 mg/kg daily with or without flucytosine 25 mg/kg 4 times daily for 2 weeks, OR
  • Flucytosine alone at 25 mg/kg 4 times daily for 2 weeks 1

For Fungus Balls

• Surgical intervention strongly recommended 1, 2
• Systemic antifungal therapy:
  • Fluconazole 200-400 mg (3-6 mg/kg) daily, OR
  • Amphotericin B deoxycholate 0.5-0.7 mg/kg daily with or without flucytosine 1
• If access to renal collecting system is available: Irrigation with amphotericin B (50 mg/L sterile water) as adjunct therapy 1

Important Management Considerations

Non-pharmacological Interventions

• Remove indwelling bladder catheters if present 2, 4
• Eliminate urinary tract obstruction 2
• Consider removal/replacement of nephrostomy tubes or stents 2
• Correct predisposing factors (obstruction, stones, foreign bodies) 2, 5

Treatment Duration

• Continue until symptoms have resolved and urine cultures no longer yield Candida species 1, 2
• Minimum of 2 weeks for symptomatic infections 2

Follow-up

• Obtain follow-up urine cultures to document clearance 2

Common Pitfalls to Avoid

1. Overtreatment: Most asymptomatic candiduria cases resolve spontaneously without treatment 4, 5
2. Inappropriate antifungal selection: Echinocandins (caspofungin, micafungin, anidulafungin) are generally ineffective for UTIs due to minimal urinary excretion 2, 6
3. Failure to identify Candida species: C. glabrata and C. krusei may be fluconazole-resistant and require alternative therapy 2, 7
4. Inadequate duration: Premature discontinuation before symptom resolution and culture clearance may lead to recurrence 1, 2
5. Neglecting underlying factors: Failing to address predisposing conditions like catheters or obstruction reduces treatment success 2, 4