What is the treatment for yeast in urine, specifically a Candida urinary tract infection?

Treatment of Candida Urinary Tract Infections

For symptomatic Candida urinary tract infections, oral fluconazole at a dosage of 200 mg (3 mg/kg) daily for 2 weeks is the recommended first-line treatment for fluconazole-susceptible species. 1

Treatment Algorithm Based on Clinical Presentation

Asymptomatic Candiduria

• Treatment is generally not recommended unless the patient belongs to a high-risk group 1, 2
• High-risk groups requiring treatment:
  • Neutropenic patients
  • Very low-birth-weight infants
  • Patients undergoing urologic procedures 1, 2
• For patients undergoing 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 Candida UTIs

1. For Candida cystitis (lower UTI):

   • Fluconazole-susceptible species: Oral fluconazole 200 mg daily for 2 weeks 1, 3
   • Fluconazole-resistant species (including C. krusei):
     • 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

2. For Candida pyelonephritis (upper UTI):

   • Fluconazole-susceptible species: Oral fluconazole 200-400 mg daily for 2 weeks 1
   • Fluconazole-resistant species:
     • Amphotericin B deoxycholate 0.5-0.7 mg/kg daily with or without flucytosine 25 mg/kg 4 times daily OR
     • Flucytosine alone at 25 mg/kg 4 times daily for 2 weeks 1

3. For fungus balls:

   • Surgical intervention is strongly recommended in non-neonates 1, 2
   • Plus systemic antifungal therapy:
     • Fluconazole 200-400 mg 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 deoxycholate (50 mg/L sterile water) 1, 2

Important Management Considerations

Elimination of Predisposing Factors

• Remove indwelling urinary catheters if present
• Discontinue unnecessary antibiotics
• Address urinary tract obstruction if present 1, 2, 4
• Removing these factors alone resolves candiduria in approximately 50% of cases 2, 5

Antifungal Selection Considerations

• Fluconazole: Achieves high urinary concentrations and is the drug of choice for susceptible species 3, 4, 5
• Amphotericin B deoxycholate: Effective alternative for fluconazole-resistant species, achieving high urinary concentrations 2
• Avoid:
  • Echinocandins (caspofungin, micafungin, anidulafungin) due to poor urinary concentrations 2, 5
  • Newer azoles (voriconazole, posaconazole) due to poor urinary concentrations 2
  • Lipid formulations of amphotericin B for lower UTIs 2

Treatment Duration

• Continue treatment for 2 weeks or until symptoms resolve and urine cultures become negative 1, 2
• Obtain follow-up urine cultures to confirm eradication 2

Common Pitfalls to Avoid

1. Treating asymptomatic candiduria unnecessarily in low-risk patients 2
2. Failing to remove indwelling catheters or address underlying conditions 2, 5
3. Using antifungals with poor urinary concentrations (echinocandins, newer azoles) for uncomplicated UTIs 2, 5
4. Using flucytosine as monotherapy due to risk of resistance development 2
5. Not distinguishing between colonization and true infection 2, 4

By following this evidence-based approach, clinicians can effectively manage Candida urinary tract infections while avoiding unnecessary treatment in cases of asymptomatic candiduria.