What is the initial treatment for a patient diagnosed with a Candida Urinary Tract Infection (UTI)?

Initial Treatment for Candida Urinary Tract Infection (UTI)

Fluconazole 200 mg (3 mg/kg) daily for 2 weeks is the first-line treatment for symptomatic Candida UTI. 1

Diagnosis Confirmation

Before initiating treatment, confirm that the candiduria represents true infection rather than colonization or contamination:

• Obtain a second urine sample to confirm persistent candiduria
• Assess for symptoms: dysuria, frequency, urgency, suprapubic pain
• Evaluate risk factors: diabetes mellitus, indwelling catheters, broad-spectrum antibiotics, urinary obstruction, ICU admission

Treatment Algorithm

1. First Steps

• Remove indwelling urinary catheters whenever possible (resolves candiduria in nearly 50% of cases) 1
• Correct predisposing factors (obstruction, stones, foreign bodies)

2. Antifungal Therapy Based on Candida Species

• C. albicans (most common, ~60% of isolates):

  • Fluconazole 200 mg daily for 2 weeks 1
  • Alternative dosing: 200 mg loading dose followed by 100 mg daily for at least 4 days 2

• Fluconazole-resistant species (e.g., C. glabrata):

  • Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1
  • Alternative: Flucytosine 25 mg/kg 4 times daily for 7-10 days 1

• C. krusei infections:

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

3. Treatment Based on Infection Site

• Cystitis: Fluconazole 200 mg daily for 2 weeks 1
• Pyelonephritis: Fluconazole 200-400 mg daily for 2 weeks OR amphotericin B deoxycholate 0.5-0.7 mg/kg daily with or without flucytosine 1, 3
• Fungus balls: Surgical removal with adjunctive antifungal therapy (fluconazole or amphotericin B) 1

Important Considerations

• Echinocandins (caspofungin, micafungin, anidulafungin) are generally ineffective for UTIs due to minimal urinary excretion 1, 4
• Lipid formulations of amphotericin B and most azoles (except fluconazole) have poor urinary concentrations and should not be used as first-line agents 1
• For patients with nephrostomy tubes or stents, consider removal or replacement 1
• In cases with access to the renal collecting system, irrigation with Amphotericin B deoxycholate (50 mg/L sterile water) may be considered as adjunctive treatment 1

Follow-Up

• Obtain follow-up urine cultures to document clearance of infection 1
• Continue treatment until symptoms resolve and urine cultures no longer yield Candida species 1
• Minimum treatment duration for symptomatic infections is 2 weeks 1

Caution

• Inadequate treatment duration may lead to recurrence 1
• Failure to identify the Candida species may lead to inadequate treatment, as C. glabrata and C. krusei may be fluconazole-resistant 1
• Asymptomatic candiduria generally does not require treatment except in high-risk patients (neutropenic patients, very low birth weight infants, and patients undergoing urologic procedures) 1, 5