What is the treatment for Candida (fungal) urinary tract infection (UTI)?

Treatment for Candida Urinary Tract Infection

For symptomatic fungal urinary tract infections, oral fluconazole 200 mg daily for 2 weeks is the recommended first-line treatment. 1

Diagnostic Approach

• Confirm fungal UTI with urine culture showing ≥10³ fungal cells/mm³ 2
• Distinguish between asymptomatic candiduria and symptomatic infection
• Obtain blood cultures to rule out fungemia, especially if fever is present 1
• Complete metabolic panel to assess renal function, electrolytes, and glucose levels 1

Treatment Algorithm

Step 1: Assess Need for Treatment

• Asymptomatic candiduria:
  • Generally does not require antifungal treatment 1, 3
  • Resolves without treatment in approximately 76% of cases 1
  • Exceptions (treat even if asymptomatic):
    • Neutropenic patients
    • Very low birth weight infants
    • Patients undergoing urologic procedures
    • Suspected disseminated infection 1, 3

Step 2: Address Underlying Factors

• Remove indwelling bladder catheters (resolves candiduria in ~50% of cases) 1, 4
• Eliminate urinary tract obstruction if present 1
• Remove or replace nephrostomy tubes/stents 1
• Ensure adequate hydration 1
• Limit broad-spectrum antibiotics 2
• Optimize diabetes management 2

Step 3: Antifungal Therapy for Symptomatic Infections

• First-line treatment:

  • Oral fluconazole 200 mg daily for 2 weeks 1, 5
  • Alternative dosing: 200 mg loading dose followed by 100 mg/day for at least 4 days 6

• For fluconazole-resistant species:

  • Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1, 3
  • Flucytosine 25 mg/kg 4 times daily for 7-10 days 1

• For patients with renal impairment on dialysis:

  • Fluconazole 200 mg after each dialysis for cystitis
  • Fluconazole 200-400 mg after each dialysis for pyelonephritis 1

Step 4: Consider Adjunctive Measures

• For fungal balls or abscesses: surgical debridement plus systemic antifungal therapy 1
• For nephrostomy tubes: consider irrigation with amphotericin B deoxycholate 1
• Local irrigation with amphotericin B at 50 mg/L of sterile water as adjunct to systemic therapy 1

Important Considerations

• Echinocandins (micafungin, caspofungin) and newer azoles should not be used for uncomplicated fungal UTIs due to poor urinary concentrations 1, 3, 4
• Exception: Echinocandins may be considered when infection has invaded renal tissue or for azole-resistant species when other options aren't viable 1
• Treatment duration is typically 2 weeks or until symptoms resolve and urine cultures become negative 1
• Follow-up urine cultures should be obtained to confirm eradication 1

Common Pitfalls to Avoid

• Treating asymptomatic candiduria in low-risk patients (unnecessary and promotes resistance) 1, 3
• Failing to remove indwelling catheters (removal alone resolves ~50% of cases) 1, 4
• Using antifungals with poor urinary concentration (echinocandins, newer azoles) 1, 4
• Missing disseminated candidiasis (obtain blood cultures in febrile patients) 1
• Inadequate treatment duration (continue until symptoms resolve and cultures negative) 1