Treatment of Yeast in Urine (Candiduria)
Fluconazole 200 mg (3 mg/kg) daily for 2 weeks is the first-line treatment for symptomatic Candida urinary tract infections caused by fluconazole-susceptible species. 1, 2
Diagnostic Approach
- Candiduria with symptoms (like urinary frequency) suggests true infection rather than colonization, requiring treatment 1
- Asymptomatic candiduria generally does not require treatment unless the patient has specific risk factors 3, 4
- Imaging (ultrasound or CT) may be helpful to rule out structural abnormalities or fungus ball formation in patients with candiduria 1
Treatment Algorithm Based on Clinical Presentation
For Symptomatic Candida Cystitis:
- First-line therapy: Fluconazole 200 mg (3 mg/kg) daily for 2 weeks 1, 3
- Alternative loading dose regimen: 200 mg loading dose followed by 100 mg daily for at least 4 days 5
- Treatment should continue until symptoms resolve and urine cultures no longer yield Candida species 2, 1
For Fluconazole-Resistant Species (C. glabrata, C. krusei):
- Amphotericin B deoxycholate (AmB-d) 0.3-0.6 mg/kg daily for 1-7 days 1, 4
- Oral flucytosine 25 mg/kg 4 times daily for 7-10 days 1, 2
- For fungus balls: Surgical debridement plus systemic antifungal therapy; consider local irrigation with AmB-d at 50 mg/L of sterile water if direct access to the collecting system is available 2, 6
For Candida Pyelonephritis:
- Fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks for susceptible organisms 3, 2
- Amphotericin B deoxycholate is recommended for resistant species 2, 4
Special Populations Requiring Treatment Even When Asymptomatic
- Neutropenic patients 3, 4
- Low birth weight infants 3, 2
- Patients undergoing urologic procedures (treat with fluconazole several days before and after) 3, 1
- Severely immunocompromised patients with fever and candiduria 3, 4
- Patients with urinary tract obstruction 3
Important Clinical Considerations
- Fluconazole is preferred due to excellent urinary concentration of active drug 3, 7
- Echinocandins and other azoles (besides fluconazole) have minimal urinary excretion and are generally ineffective for Candida UTI 1, 7
- Lipid formulations of amphotericin B do not achieve adequate urine concentrations and should not be used for treating Candida UTI 1, 2
- Removing predisposing factors (indwelling catheters, antibiotics) will clear candiduria in almost 50% of asymptomatic patients 7
Common Pitfalls to Avoid
- Treating asymptomatic candiduria in patients without risk factors for dissemination 1, 4
- Using antifungal agents with poor urinary excretion (echinocandins, voriconazole) for lower urinary tract infections 1, 6
- Overlooking the possibility of disseminated candidiasis in high-risk patients with candiduria 1, 3
- Failing to remove or replace indwelling urinary catheters when possible 7, 6