Treatment of Candida krusei in Urine Culture for an 81-Year-Old Male with Leukocytosis
For Candida krusei urinary tract infection, amphotericin B deoxycholate at 0.3-0.6 mg/kg daily for 1-7 days is the recommended treatment. 1
Assessment and Initial Management
- First determine if this represents true infection requiring treatment or asymptomatic candiduria 1
- Treatment is NOT recommended for asymptomatic candiduria unless the patient belongs to a high-risk group for dissemination 1
- High-risk groups include neutropenic patients, very low birth-weight infants, and patients undergoing urologic manipulation 1
- Given the patient's advanced age (81 years) and leukocytosis, treatment is likely warranted as these factors suggest potential for systemic spread 1
Treatment Algorithm for C. krusei UTI
Step 1: Remove predisposing factors
- Remove indwelling bladder catheter if present (strongly recommended) 1, 2
- Eliminate any urinary tract obstruction if present 1
- Consider removal or replacement of nephrostomy tubes or stents if present 1
Step 2: Initiate antifungal therapy
- C. krusei is inherently resistant to fluconazole 3
- First-line treatment: Amphotericin B deoxycholate, 0.3-0.6 mg/kg daily for 1-7 days 1
- Alternative option: AmB deoxycholate bladder irrigation, 50 mg/L sterile water daily for 5 days (for cystitis) 1
Step 3: For complicated cases
- If renal fungal balls are present, surgical intervention is strongly recommended 1
- For nephrostomy tubes, irrigation with AmB deoxycholate (25-50 mg in 200-500 mL sterile water) 1
- For severe/systemic infection, consider echinocandin therapy (caspofungin: 70-mg loading dose, then 50 mg daily) 4, 5
Special Considerations for This Patient
- Advanced age (81 years) increases risk of disseminated infection 3
- Leukocytosis suggests inflammatory response, possibly indicating true infection rather than colonization 3
- Monitor renal function closely during amphotericin B therapy due to nephrotoxicity risk, especially important in elderly patients 6
- Echinocandins (like caspofungin) may be considered in cases of severe infection or amphotericin B intolerance, though they achieve lower urinary concentrations 5, 2
Monitoring and Follow-up
- Repeat urine cultures to document clearance of infection 1
- Monitor for signs of disseminated candidiasis (persistent fever, hypotension) 3
- For cystitis, treat for 2 weeks 1
- For pyelonephritis, treat for 2 weeks and ensure resolution of symptoms and negative cultures 1
Pitfalls and Caveats
- Do not use fluconazole for C. krusei as it has intrinsic resistance 3
- Echinocandins (caspofungin, micafungin, anidulafungin) achieve poor urinary concentrations and are not first-line for UTI, though they may be used for systemic infection 2
- Amphotericin B can cause significant nephrotoxicity, particularly in elderly patients - monitor renal function closely 6
- Failure to remove catheters or stents can lead to persistent infection 1, 2
- Inadequate treatment duration may result in recurrence 1