What is the appropriate treatment for a patient with a urinary tract infection (UTI) who has yeast present in their urine?

Management of Yeast in Urine (Candiduria)

For patients with yeast in urine, treatment is NOT recommended for asymptomatic candiduria unless the patient belongs to a high-risk group (neutropenic patients, very low-birth-weight infants, patients undergoing urologic procedures, or those with suspected disseminated infection). 1, 2

Assessment and Diagnosis

• Determine if candiduria represents:

  • Asymptomatic colonization
  • Symptomatic cystitis
  • Pyelonephritis
  • Disseminated infection

• Key diagnostic considerations:

  • Presence of symptoms (dysuria, frequency, urgency, suprapubic pain)
  • Risk factors (indwelling catheters, diabetes, immunosuppression)
  • Urine culture to confirm Candida species and susceptibility

Management Algorithm

1. Asymptomatic Candiduria

• First step: Eliminate predisposing factors 1, 2

  • Remove indwelling bladder catheters (resolves candiduria in ~50% of cases)
  • Discontinue unnecessary antibiotics
  • Control underlying conditions (e.g., diabetes)

• Treatment indications: Only treat if patient belongs to high-risk groups:

  • Neutropenic patients → Treat as for candidemia
  • Very low-birth-weight infants → Treat as for candidemia
  • Patients undergoing urologic procedures → Fluconazole 400 mg daily or AmB deoxycholate 0.3-0.6 mg/kg daily for several days before and after procedure 1

2. Symptomatic Candida Cystitis

• First-line treatment: Fluconazole 200 mg daily for 2 weeks 1, 2
• For fluconazole-resistant C. glabrata:
  • AmB deoxycholate 0.3-0.6 mg/kg daily for 1-7 days OR
  • Flucytosine 25 mg/kg 4 times daily for 7-10 days 1
• For C. krusei: AmB deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1

3. Candida Pyelonephritis

• First-line treatment: Fluconazole 200-400 mg daily for 2 weeks 1
• For fluconazole-resistant C. glabrata:
  • AmB deoxycholate 0.3-0.6 mg/kg daily for 1-7 days with or without flucytosine 25 mg/kg 4 times daily 1
• For suspected disseminated candidiasis: Treat as for candidemia 1

4. Fungal Urinary Tract Obstruction (Fungus Balls)

• Management:
  • Surgical removal strongly recommended 1
  • Systemic antifungal therapy: Fluconazole 200-400 mg daily 1
  • Consider local irrigation with AmB deoxycholate as adjunctive therapy 2

Special Considerations

• Catheter management: Always remove or replace indwelling catheters when possible 1, 2
• Fluconazole advantages:
  • Achieves high urinary concentrations 3, 4
  • Available in both oral and IV formulations
  • FDA-approved for candidal UTIs 3
• Newer azoles and echinocandins: Not recommended for isolated urinary tract infections due to poor urinary concentrations 4
• Follow-up: Obtain follow-up urine cultures to confirm eradication 2

Common Pitfalls to Avoid

1. Overtreating asymptomatic candiduria in low-risk patients (resolves spontaneously in ~76% of cases) 2
2. Failing to remove predisposing factors like catheters or unnecessary antibiotics
3. Using echinocandins or newer azoles as first-line therapy for isolated UTIs
4. Not distinguishing colonization from true infection
5. Missing disseminated candidiasis in patients with candiduria and systemic symptoms

Remember that the presence of yeast in urine does not always indicate infection and often represents colonization, especially in catheterized patients. Treatment decisions should be based on symptoms, risk factors, and the specific Candida species identified.