What is the recommended treatment for a patient with symptomatic candiduria showing 100,000 colony-forming units (CFU) of yeast, likely Candida, in a urine culture?

Treatment of Symptomatic Candiduria with 100,000 CFU/mL

For symptomatic candiduria with 100,000 CFU/mL of yeast, oral fluconazole 200 mg (3 mg/kg) daily for 14 days is the recommended first-line treatment. 1

Assessment and Initial Management

When evaluating a patient with symptomatic candiduria showing 100,000 colony-forming units (CFU) of yeast:

1. Confirm true infection vs. colonization:

   • Ensure symptoms are present (dysuria, frequency, urgency)
   • Verify with a second sterile urine sample to rule out contamination
   • Check for pyuria (white blood cells in urine)

2. Initial interventions:

   • Remove indwelling catheter if present (resolves candiduria in ~40% of cases) 1
   • Discontinue unnecessary antibiotics if possible

Treatment Algorithm

For Fluconazole-Susceptible Candida Species (including C. albicans):

• First-line treatment: Oral fluconazole 200 mg (3 mg/kg) daily for 14 days 1, 2
• Clinical success rates with fluconazole range from 53-88% in various studies 1, 3

For Fluconazole-Resistant Species (e.g., C. glabrata, C. krusei):

• Option 1: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1, 2
• Option 2: Oral flucytosine 25 mg/kg 4 times daily for 7-10 days 1
• Option 3 (for refractory cases): Amphotericin B bladder irrigation (50 mg/L sterile water) 1, 2

Special Considerations

For Pyelonephritis:

If upper tract infection is suspected (fever, flank pain, systemic symptoms):

• Increase fluconazole dose to 400 mg (6 mg/kg) daily for 14 days 1, 4
• For fluconazole-resistant strains: Amphotericin B deoxycholate 0.5-0.7 mg/kg daily with or without flucytosine 1

For Fungus Balls:

• Surgical intervention is strongly recommended 1, 2
• Systemic antifungal therapy as above

Monitoring and Follow-up

• Obtain follow-up urine cultures to document clearance
• Monitor renal function if using amphotericin B
• Assess for clinical improvement of symptoms

Important Caveats

• Echinocandins (caspofungin, micafungin, anidulafungin) are not recommended for urinary tract infections due to poor urinary concentrations 1, 5
• Voriconazole and other newer azoles also achieve inadequate urine concentrations and are not recommended 1, 6
• Candiduria in neutropenic patients, critically ill patients, and transplant recipients may represent disseminated candidiasis and requires more aggressive management 1
• Non-albicans Candida species are increasingly common in nosocomial urinary tract infections (up to 71.4% in some studies) 7, highlighting the importance of species identification when possible

The evidence strongly supports fluconazole as first-line therapy for symptomatic candiduria due to its excellent urinary penetration, with appropriate alternatives for resistant organisms based on susceptibility patterns.