What is the treatment for urogenital candidiasis?

Treatment of Urogenital Candidiasis

For urogenital candidiasis, fluconazole is the first-line treatment, with 200 mg daily for 2 weeks recommended for urinary tract infections and a single 150 mg dose for uncomplicated vulvovaginal candidiasis. 1, 2

Candidiasis of the Urinary Tract

First-line approach:

• Remove predisposing factors, especially urinary catheters, which can resolve candiduria in approximately 40% of patients without additional treatment 2
• For susceptible organisms, fluconazole 200 mg daily for 2 weeks is the treatment of choice 2, 3
• Fluconazole is preferred because it achieves high urinary concentrations in both oral and intravenous formulations 3

For fluconazole-resistant species:

• For C. glabrata: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days OR flucytosine 25 mg/kg 4 times daily for 7-10 days 2
• For C. krusei: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 2
• For refractory cystitis due to azole-resistant organisms: Bladder irrigation with amphotericin B deoxycholate (50 mg/L sterile water) may be considered, though there is a high relapse rate 1, 2

For pyelonephritis:

• Fluconazole is the drug of choice for most cases 1
• For C. glabrata pyelonephritis: Amphotericin B deoxycholate with or without flucytosine 1, 2
• Lipid formulations of amphotericin B should not be used for urinary tract infections as they achieve poor urinary concentrations 1, 4

Important considerations:

• Echinocandins (caspofungin, micafungin, anidulafungin) are not recommended for standard Candida UTIs due to poor urinary concentrations 1
• Elimination of urinary tract obstruction is essential for successful treatment 2
• For patients with nefrostomies or stents, consider removal or replacement if possible 2

Vulvovaginal Candidiasis (VVC)

Uncomplicated VVC:

• Single 150 mg dose of oral fluconazole is effective and convenient 1, 2, 5
• Alternative: Topical antifungal agents (no agent has proven superiority over others) 1, 2, 6

Complicated VVC:

• For severe acute VVC: Fluconazole 150 mg every 72 hours for a total of 2-3 doses 2
• For non-albicans species or azole-resistant infections:
  • Boric acid 600 mg intravaginal capsules daily for 14 days 2
  • Nystatin intravaginal suppositories (100,000 units daily for 14 days) 2
  • Topical flucytosine 17% cream alone or combined with amphotericin B 3% cream daily for 14 days 2

Recurrent VVC:

• Induction therapy with topical agent or oral fluconazole for 10-14 days 1, 2
• Followed by maintenance therapy with fluconazole 150 mg weekly for 6 months 1, 2

Special Considerations

Diabetic patients:

• More aggressive treatment may be needed as diabetes is a risk factor for complicated and recurrent infections 7
• Optimal glycemic control should be emphasized as part of treatment 7

Pregnant women:

• Topical azoles are preferred over oral agents due to safety concerns 6
• Longer duration of therapy (7 days) may be needed 2

Immunocompromised patients:

• May require longer duration of therapy and higher doses 8
• Close monitoring for treatment response is essential 8

Common Pitfalls to Avoid

• Treating asymptomatic candiduria in non-catheterized, non-neutropenic patients is generally unnecessary 1, 4
• Avoid lipid formulations of amphotericin B for urinary tract infections due to poor urinary concentrations 1, 4
• Do not use echinocandins as first-line therapy for Candida UTIs despite their efficacy for systemic candidiasis 1
• Recognize that removal of catheters alone may resolve candiduria in many patients, avoiding unnecessary antifungal use 2, 3