Do I treat budding yeast on a Urinalysis (UA)?

Management of Budding Yeast on Urinalysis

Treatment is not recommended for asymptomatic candiduria (budding yeast on UA) unless the patient belongs to a high-risk group for dissemination. 1

When to Treat vs. When to Observe

No Treatment Needed (Observation Only):

• Asymptomatic patients with no predisposing conditions only require observation 1
• Elimination of predisposing factors (such as removing indwelling catheters) often results in spontaneous resolution of candiduria in approximately 40% of patients 1, 2
• Most cases of candiduria represent colonization rather than infection, especially in catheterized patients 3, 4

High-Risk Patients Requiring Treatment Despite Being Asymptomatic:

• Neutropenic patients 1
• Infants with low birth weight 1
• Patients undergoing urologic procedures/manipulations 1
• Severely immunocompromised patients with fever and candiduria 1
• Patients with urinary tract obstruction 1

Treatment Approach for Specific Scenarios

For Patients Undergoing Urologic Procedures:

• Fluconazole 200-400 mg (3-6 mg/kg) daily for several days before and after the procedure 1
• Alternative: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for several days before and after the procedure 1

For Symptomatic Candida Cystitis:

• Fluconazole 200 mg (3 mg/kg) daily for 2 weeks for fluconazole-susceptible species 1
• For fluconazole-resistant organisms (especially C. glabrata):
  • Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1
  • OR oral flucytosine 25 mg/kg 4 times daily for 7-10 days 1

For Candida Pyelonephritis:

• Fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks for susceptible organisms 1
• For fluconazole-resistant strains:
  • Amphotericin B deoxycholate 0.5-0.7 mg/kg daily with or without flucytosine 1
  • OR flucytosine alone 25 mg/kg 4 times daily for 2 weeks 1

Important Clinical Considerations

Diagnostic Considerations:

• Candiduria is typically defined as >10³ fungal cells/mm³ in urine 5
• No established cutoff for leukocyte concentration has been defined 5
• Candida albicans is the most commonly isolated species, but previous antifungal treatment and hospitalization can affect species distribution and susceptibility 5

Treatment Selection Factors:

• Fluconazole is the preferred agent for most Candida UTIs due to:
  • Excellent urinary concentration of active drug 1, 2
  • Available in both oral and IV formulations 4
  • Generally well-tolerated 4
• Newer azoles and echinocandins are not recommended for urinary tract infections as they fail to achieve adequate urine concentrations 2

Common Pitfalls to Avoid:

• Treating all cases of candiduria - most are colonization, not infection 3, 4
• Failing to remove predisposing factors (catheters, antibiotics) before initiating antifungal therapy 2
• Using echinocandins or newer azoles for urinary tract infections 2
• Overlooking the possibility of disseminated candidiasis in high-risk patients with candiduria 1
• Failing to distinguish between lower and upper urinary tract infections, which require different management approaches 6

By following these evidence-based guidelines, clinicians can appropriately manage budding yeast on urinalysis while avoiding unnecessary antifungal use and ensuring proper treatment for high-risk patients.