Treatment of Candida UTI in Hemodialysis Patients
For urinary tract infections caused by Candida in hemodialysis patients, oral fluconazole at a dose of 200-400 mg daily for 2 weeks is the recommended first-line treatment for fluconazole-susceptible species. 1
Treatment Algorithm Based on Candida Species
Fluconazole-Susceptible Candida (including C. albicans)
- Oral fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks 1
- Remove indwelling bladder catheter if present 1
- Eliminate urinary tract obstruction if present 1
Fluconazole-Resistant C. glabrata
- Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1
- Alternative: oral flucytosine 25 mg/kg 4 times daily for 7-10 days 1
- Consider combination therapy with amphotericin B deoxycholate plus flucytosine for severe infections 1
C. krusei Infections
- Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1
- Remove indwelling catheter if present 1
Special Considerations for Hemodialysis Patients
- Fluconazole requires dose adjustment in hemodialysis patients - administer the full dose (200-400 mg) after each dialysis session 2
- Monitor for drug interactions between antifungals and other medications commonly used in hemodialysis patients 3
- Amphotericin B formulations should be used with caution due to potential nephrotoxicity, even in patients already on dialysis 1
- For patients with fungus balls or severe obstruction, consider surgical intervention 1
Management Based on Infection Site
Candida Cystitis
- Fluconazole 200 mg daily for 2 weeks for susceptible species 1
- For resistant species, consider amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) as adjunctive therapy 1
- Remove indwelling catheter if present 1
Candida Pyelonephritis
- Fluconazole 200-400 mg daily for 2 weeks for susceptible species 1
- For resistant species, amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days with or without flucytosine 1
- Address any urinary tract obstruction or stents/nephrostomy tubes 1
- Consider replacement of nephrostomy tubes or stents if present 1
Fungus Ball or Severe Infection
- Surgical intervention is strongly recommended 1
- Systemic antifungal therapy as outlined above 1
- Consider irrigation through nephrostomy tubes with amphotericin B deoxycholate (25-50 mg in 200-500 mL sterile water) if tubes are present 1, 3
Important Caveats
- Echinocandins (caspofungin, micafungin, anidulafungin) achieve minimal urinary concentrations and are not recommended for Candida UTI 3, 4
- Newer azoles (voriconazole, posaconazole) also do not achieve adequate urine concentrations 4
- Asymptomatic candiduria generally does not require treatment unless the patient is at high risk for dissemination 1, 2
- For patients undergoing urologic procedures, prophylactic fluconazole 400 mg daily or amphotericin B deoxycholate 0.3-0.6 mg/kg daily for several days before and after the procedure is recommended 1
- Treatment duration should be extended if resolution is delayed or if there are signs of systemic infection 1, 2