When can a patient with a fungal Urinary Tract Infection (UTI) be cleared for a mesh operation?

Management of Fungal UTI Before Mesh Operation

A patient with a fungal UTI should be treated with appropriate antifungal therapy and documented clearance of infection with negative urine cultures before proceeding with mesh operation to minimize the risk of mesh infection and potential explantation. 1

Treatment of Fungal UTI

• Fluconazole is the antifungal agent of choice for treating fungal UTIs, as it achieves high urine concentrations with oral formulation 2
• For non-critically ill patients with candidal UTI, fluconazole 200-400 mg (3-6 mg/kg) daily for 14 days is recommended 1
• For critically ill patients or those with a history of recent azole exposure, echinocandins are recommended as first-line therapy 1
• Treatment should be continued until complete resolution of symptoms and negative urine cultures are obtained 1
• Removal of predisposing factors, such as indwelling catheters, will clear candiduria in almost 50% of asymptomatic patients 2

Timing of Mesh Operation After Fungal UTI

• Mesh operations should be delayed until complete resolution of the fungal UTI with documented negative urine cultures 1
• At minimum, a 14-day course of appropriate antifungal therapy should be completed before considering mesh placement 1
• Documentation of at least one negative urine culture after completion of antifungal therapy is essential before proceeding with mesh operation 3, 4

Rationale for Delayed Mesh Placement

• Mesh infection is a devastating complication of hernioplasties with a reported rate of 1.9% 1
• Postoperative surgical site infection significantly increases the risk of mesh infection (OR 2.9; CI 1.55 to 4.10) 1
• 72.7% of mesh infections require mesh explantation, significantly increasing morbidity and mortality 1
• The presence of active infection at the time of surgery is a significant risk factor for subsequent mesh infection 1
• Fungal biofilms can provide protection against host immune cells and antibiotics, making eradication difficult once established 1

Special Considerations

• For patients with fungal balls or casts in the urinary tract, surgical intervention may be required in addition to antifungal therapy 1
• In cases where urgent hernia repair is needed despite active fungal UTI, consider:
  • Non-mesh primary repair if the defect is small (<3 cm) 1
  • Use of biological mesh rather than synthetic mesh in contaminated fields if primary repair is not feasible 1
• Patients with recurrent fungal UTIs may benefit from longer courses of antifungal therapy and more thorough evaluation before mesh placement 5

Monitoring Before and After Mesh Placement

• Obtain a urine culture before initiating antifungal therapy to guide treatment 4
• Document negative urine cultures after completion of antifungal therapy and before mesh placement 3
• Consider repeat urine culture 1-2 days before the scheduled mesh operation to confirm continued absence of infection 4
• Monitor for signs of surgical site infection postoperatively, as this can lead to mesh infection 1

Common Pitfalls to Avoid

• Do not proceed with mesh placement in the presence of active fungal UTI, as this significantly increases the risk of mesh infection 1
• Avoid treating asymptomatic candiduria in non-high-risk patients, as this leads to unnecessary antifungal use 3
• Do not rely solely on symptom resolution without documented negative urine cultures before proceeding with mesh operation 4
• Recognize that fungal UTIs may be indolent and present with minimal symptoms, requiring thorough evaluation 1