What is the recommended treatment for pediatric candiduria?

Treatment of Pediatric Candiduria

For pediatric candiduria, treatment is NOT recommended unless the patient belongs to a high-risk group for dissemination (neutropenic patients, very low-birth-weight infants <1500g, or patients undergoing urologic manipulation). 1

Assessment and Management Algorithm

Step 1: Determine if treatment is necessary

• No treatment needed for most cases

  • Elimination of predisposing factors (especially indwelling bladder catheters) is the primary intervention 1
  • Most cases of candiduria represent colonization rather than infection, particularly in catheterized patients 1

• Treatment required only for high-risk groups:

  1. Neutropenic patients
  2. Very low-birth-weight infants (<1500g)
  3. Patients undergoing urologic manipulation
  4. Symptomatic patients with signs of urinary tract infection

Step 2: Treatment recommendations for specific populations

For high-risk patients requiring treatment:

1. Neutropenic patients and very low-birth-weight infants:

   • Treat as recommended for candidemia 1
   • Amphotericin B deoxycholate 1 mg/kg daily is recommended for neonates 1
   • Fluconazole 12 mg/kg daily is a reasonable alternative in patients without prior fluconazole prophylaxis 1

2. Patients undergoing urologic procedures:

   • Oral fluconazole 400 mg (6 mg/kg) daily OR
   • Amphotericin B deoxycholate 0.3-0.6 mg/kg daily
   • Administer for several days before and after the procedure 1

3. For symptomatic candiduria with fluconazole-susceptible organisms:

   • Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks 1
   • For infants: fluconazole 6 mg/kg daily 2

4. 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

5. For C. krusei:

   • Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1

Step 3: Additional interventions

• Remove indwelling bladder catheters whenever feasible (strongly recommended) 1
• Eliminate urinary tract obstruction if present 1
• For persistent candiduria with fluconazole-resistant species, consider amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) 1

Special Considerations for Pediatric Dosing

• Fluconazole dosing in children:

  • Standard dose: 6 mg/kg daily 3, 4
  • For neonates in first 2 weeks of life: same mg/kg dose but administered every 72 hours 3, 4
  • For neonates 2-4 weeks of life: same dose every 48 hours 4
  • After 4 weeks: daily dosing 4

• Renal adjustment:

  • For creatinine clearance ≤50 mL/min: reduce dose by 50% 3
  • For hemodialysis patients: give 100% of dose after each hemodialysis 3

Monitoring and Follow-up

• Obtain follow-up urine cultures to document clearance
• For persistent candiduria, consider ultrasound or CT scan of the kidneys 1
• Monitor renal function during treatment, especially with amphotericin B

Common Pitfalls to Avoid

1. Overtreating asymptomatic candiduria in low-risk patients, which may select for resistant organisms 1
2. Failure to remove urinary catheters, which significantly reduces treatment success 1
3. Inadequate species identification - treatment should be tailored to the specific Candida species, as resistance patterns vary 1, 5
4. Not adjusting fluconazole dosing for neonates and young infants, who require different dosing schedules due to immature renal function 3, 4
5. Missing underlying structural abnormalities - candiduria may be a sign of underlying urological abnormalities in children 2

The evidence strongly supports that most cases of pediatric candiduria do not require antifungal therapy, and management should focus on removing predisposing factors. Treatment should be reserved for specific high-risk groups where the risk of dissemination is significant.