What is the treatment for candiduria?

Treatment for Candiduria

For candiduria, asymptomatic cases generally do not require treatment unless the patient is in a high-risk group, while symptomatic infections should be treated with fluconazole 200 mg daily for 2 weeks. 1

Assessment and Treatment Algorithm

Step 1: Determine if Treatment is Necessary

• Asymptomatic candiduria: Generally does not require treatment 1
• Exceptions requiring treatment despite being asymptomatic:
  • Immunocompromised patients
  • Patients undergoing urologic procedures
  • Patients with suspected disseminated fungal infections
  • Patients at extremes of age (very young or elderly) 1, 2

Step 2: Remove Predisposing Factors

• Remove or replace indwelling catheters if present (resolves candiduria in ~50% of cases) 1, 3
• Discontinue unnecessary antibiotics 3

Step 3: Treatment Based on Clinical Presentation

For Symptomatic Candida Cystitis:

• First-line: Fluconazole 200 mg loading dose, then 200 mg daily for 2 weeks 1
  • Alternative dosing per French Association of Urology: 400 mg on day 1, then 200 mg daily for 7-14 days 2

For Candida Pyelonephritis:

• First-line: Fluconazole 200-400 mg daily for 2 weeks 1
• For patients on hemodialysis: 200 mg loading dose, then 200-400 mg after each dialysis session 1

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

• Option 1: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1
• Option 2: Oral flucytosine 25 mg/kg 4 times daily for 7-10 days (never as monotherapy due to risk of resistance) 1

Special Considerations

Fungal Species

• C. albicans is most common (60% of isolates) and typically fluconazole-susceptible 2
• Non-albicans species may have variable fluconazole susceptibility 4

Complicated Cases

• For fungal balls or abscesses: Surgical debridement plus systemic antifungal therapy 1
• Consider local irrigation with amphotericin B (50 mg/L sterile water) as adjunct therapy 1

Monitoring

• Follow-up urine cultures to confirm eradication 1
• Monitor renal function during treatment, especially with amphotericin B 1
• For flucytosine, drug level monitoring is recommended 1

Important Caveats

• Diagnostic pitfall: Confirm candiduria with a second urine sample to rule out contamination 2
• Treatment pitfall: Echinocandins and newer azoles should not be used for uncomplicated candiduria due to poor urinary concentrations 1, 3
• Treatment pitfall: Lipid formulations of amphotericin B should not be used for lower urinary tract infections due to inadequate urine concentrations 1
• Overtreatment risk: Treating asymptomatic candiduria unnecessarily in non-high-risk patients should be avoided 1

Fluconazole is the preferred agent for most cases due to its excellent urinary penetration, with studies showing eradication rates of approximately 88% 5, 3.