Treatment and Duration for Fungal Acute Cystitis
For fungal acute cystitis, treatment with antifungal agents is NOT recommended unless the patient belongs to a high-risk group for dissemination, which includes neutropenic patients, very low-birth-weight infants (<1500g), or patients who will undergo urologic manipulation. 1
Treatment Approach Based on Risk Factors
Patients Not Requiring Treatment
- Elimination of predisposing factors, such as indwelling bladder catheters, is recommended whenever feasible 1
- Most immunocompetent patients with asymptomatic candiduria do not require antifungal therapy 1
High-Risk Patients Requiring Treatment
For patients who need treatment, therapy should be tailored to the specific Candida species:
Fluconazole-Susceptible Organisms (e.g., C. albicans)
- Oral fluconazole, 200 mg (3 mg/kg) daily for 2 weeks 1
- Removal of indwelling bladder catheter, if present, is strongly recommended 1
Fluconazole-Resistant C. glabrata
- AmB 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
- For persistent infections, monotherapy with oral flucytosine, 25 mg/kg 4 times daily for 2 weeks could be considered 1
C. krusei Infections
- AmB deoxycholate, 0.3-0.6 mg/kg daily for 1-7 days 1
Special Considerations
- For patients undergoing urologic procedures with fungal cystitis:
- Oral fluconazole, 400 mg (6 mg/kg) daily, OR
- AmB deoxycholate, 0.3-0.6 mg/kg daily
- Treatment should be administered for several days before and after the procedure 1
Adjunctive Therapies
Bladder Irrigation
- AmB deoxycholate bladder irrigation (50 mg/L sterile water daily for 5 days) may be useful for treatment of cystitis due to fluconazole-resistant species, such as C. glabrata and C. krusei 1
- This approach is generally reserved for refractory cases 2
Catheter Management
- Catheter replacement alone may result in clearance of funguria in up to 87-93% of cases within 8 weeks 3
- However, combining catheter replacement with antifungal therapy leads to more rapid clearance of funguria 3
Management of Complications
Fungus Ball
- Surgical intervention (transurethral removal) is strongly recommended for fungus balls 1
- Systemic antifungal treatment as noted above for cystitis 4
- Irrigation through nephrostomy tubes, if present, with AmB deoxycholate (25-50 mg in 200-500 mL sterile water) is recommended 1
- Bladder irrigation with saline before surgery may help shrink fungus balls and decrease risk of dissemination during manipulation 4
Monitoring and Follow-up
- Follow-up urine cultures are recommended to confirm eradication of infection
- For persistent or recurrent infections, evaluation for structural abnormalities or systemic candidiasis should be considered 1
- Elimination of urinary tract obstruction is strongly recommended if present 1
Pitfalls and Caveats
- Failure to remove or replace indwelling catheters may lead to persistent infection 1
- Treating asymptomatic candiduria in non-high-risk patients is not recommended and may lead to unnecessary drug exposure and resistance 1
- Fluconazole should not be used for empiric therapy in patients who have received azole prophylaxis due to potential resistance 1
- Always consider species identification and susceptibility testing when selecting therapy, as resistance patterns vary significantly among Candida species 1