What is the treatment for a urinary tract infection caused by Candida albicans with a significant yeast count?

Treatment for Candida albicans Urinary Tract Infection

For a urinary tract infection caused by Candida albicans with a significant yeast count (10,000-100,000), oral fluconazole 200 mg daily for 2 weeks is the recommended first-line treatment. 1, 2

Diagnostic Considerations

• Candiduria with a significant yeast count (10,000-100,000) suggests infection rather than mere colonization, especially when accompanied by urinary symptoms 2
• Colony counts alone cannot reliably differentiate between colonization and infection, particularly when a catheter is present 1
• Imaging (ultrasound or CT) may be helpful to rule out structural abnormalities, hydronephrosis, or fungus ball formation in patients with candiduria 2

Treatment Algorithm

First-line Treatment

• For fluconazole-susceptible Candida albicans:
  • Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks 1, 2
  • Some sources recommend a loading dose of 400 mg on day 1, followed by 200 mg daily 3

Alternative Treatments

• For fluconazole-resistant species (though C. albicans is typically susceptible):
  • Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1, 2
  • Oral flucytosine 25 mg/kg 4 times daily for 7-10 days 1, 2

Special Considerations

• If urinary catheters or stents are present, removal or replacement should be considered as the first step of management 1, 3
• Removal of urinary catheters alone resolves candiduria in nearly half of cases 3
• For patients undergoing urologic procedures with candiduria, prophylactic treatment with fluconazole 400 mg daily or amphotericin B deoxycholate for several days before and after the procedure is recommended 1

Pharmacological Considerations

• Fluconazole is preferred due to:

  • High concentrations achieved in urine 1, 4
  • Availability in both oral and intravenous formulations 5
  • Proven effectiveness against most Candida albicans strains 1, 2

• Important limitations to avoid:

  • Echinocandins and other azoles (besides fluconazole) have minimal urinary excretion and are generally ineffective for treating Candida UTIs 2, 4
  • Lipid formulations of amphotericin B do not achieve adequate urine concentrations 2

Common Pitfalls and Caveats

• Treating asymptomatic candiduria in patients without risk factors for dissemination is generally not recommended 2, 4
• Using antifungal agents with poor urinary excretion (echinocandins, voriconazole) for lower urinary tract infections should be avoided 2
• Bladder irrigation with amphotericin B may resolve candiduria in 80-90% of catheterized patients but has high recurrence rates and is generally discouraged except in specific cases 1, 5
• Treatment should continue until symptoms have resolved and urine cultures no longer yield Candida species 2
• Overlooking the possibility of disseminated candidiasis in high-risk patients with candiduria is a common pitfall 2