Treatment of Candida auris in Urine
For Candida auris urinary tract infections, echinocandins (caspofungin, micafungin, or anidulafungin) are recommended as first-line therapy due to the multidrug-resistant nature of C. auris, despite their limited urinary excretion. 1
Treatment Algorithm Based on Clinical Presentation
Symptomatic Candiduria (Cystitis)
- For suspected C. auris cystitis, echinocandins are recommended as first-line therapy despite limited urinary excretion, due to the multidrug-resistant nature of C. auris 1
- Caspofungin (70-mg loading dose, then 50 mg daily), micafungin (100 mg daily), or anidulafungin (200-mg loading dose, then 100 mg daily) are the preferred echinocandins 2
- Liposomal amphotericin B (5 mg/kg daily) is an alternative first-line agent for C. auris UTI, particularly if there is concern for systemic spread 1
- For persistent infection, consider amphotericin B deoxycholate bladder irrigation (50 mg/L sterile water daily for 5 days) as adjunctive therapy 2
Pyelonephritis or Systemic Risk
- For upper tract infection or patients at risk for dissemination, use systemic therapy with an echinocandin 1
- Combination therapy may be considered for severe infections or treatment failures (echinocandin plus amphotericin B) 1
- Flucytosine (25 mg/kg 4 times daily) may be added as part of combination therapy for resistant isolates 2, 1
Special Considerations for C. auris
- C. auris differs from other Candida species due to its multidrug resistance pattern and high transmissibility in healthcare settings 3
- Unlike treatment recommendations for other Candida species, fluconazole should not be used as first-line therapy for C. auris due to high rates of resistance 1, 3
- Antifungal susceptibility testing should be performed to guide therapy, as resistance patterns vary 3
- FKS1 mutations in C. auris can confer echinocandin resistance, necessitating alternative therapy if detected 4
Management of Urinary Catheters and Obstruction
- Remove or replace indwelling urinary catheters when possible, as this alone may resolve candiduria in up to 50% of cases 2, 5
- Elimination of urinary tract obstruction is strongly recommended as a critical part of treatment 2
- For patients with nephrostomy tubes or stents, consider removal or replacement if feasible 2
Monitoring and Follow-up
- Monitor for clinical improvement and obtain follow-up urine cultures to confirm clearance of infection 6
- For persistent infection despite appropriate therapy, consider imaging to rule out anatomical abnormalities or fungus balls 2
- Implement strict infection control measures to prevent transmission to other patients, as C. auris can persist in the healthcare environment 1, 3
Common Pitfalls to Avoid
- Do not use lipid formulations of amphotericin B for isolated lower UTI, as they do not achieve adequate urine concentrations 2
- Avoid treating asymptomatic candiduria in patients without risk factors for dissemination 2, 6
- Do not rely on standard laboratory identification methods, as C. auris is frequently misidentified as other Candida species 3
- Recognize that C. auris infections often require more aggressive treatment than other Candida species due to multidrug resistance 1, 3