Management of Candiduria (Yeast in Urine)
For asymptomatic candiduria, antifungal therapy is generally not indicated, and removal of predisposing factors such as indwelling urinary catheters is often sufficient to clear the infection. 1, 2, 3
When to Treat vs. When to Observe
- Asymptomatic candiduria in most patients does not require antifungal treatment as candidemia is rarely encountered (<5%) 1
- Removal of an indwelling urinary catheter alone is often sufficient to clear candiduria without antifungal therapy 1
- Treatment is indicated in the following specific scenarios:
- Symptomatic patients (those with urinary frequency or other symptoms) 2, 3
- Neutropenic patients 3
- Infants with low birth weight 3
- Patients undergoing urologic procedures/manipulations 3
- Severely immunocompromised patients with fever and candiduria 3
- Patients with urinary tract obstruction 3
- Candiduria in the absence of a urinary catheter in neutropenic patients with persistent unexplained fever 1
Treatment Algorithm for Symptomatic Candiduria
First-line Treatment:
- Fluconazole 200 mg (3 mg/kg) daily for 2 weeks for fluconazole-susceptible Candida species 2, 3, 4
- Fluconazole is the preferred agent due to its excellent urinary concentration of active drug 3, 4
For Fluconazole-Resistant Species (e.g., C. glabrata, C. krusei):
- Amphotericin B deoxycholate (AmB-d) 0.3-0.6 mg/kg daily for 1-7 days 2, 5
- Alternative: Oral flucytosine 25 mg/kg 4 times daily for 7-10 days 2
For Patients Undergoing Urologic Procedures:
- Fluconazole 200-400 mg (3-6 mg/kg) daily for several days before and after the procedure 3
For Candida Pyelonephritis:
- Fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks for susceptible organisms 3
Important Clinical Considerations
- C. albicans is typically susceptible to fluconazole, while C. glabrata often requires alternative therapy due to fluconazole resistance 2, 5
- Echinocandins and newer azoles (besides fluconazole) have minimal excretion into urine and are generally ineffective for treating Candida UTIs 2, 4, 5
- Lipid formulations of amphotericin B do not achieve adequate urine concentrations and should not be used 2
- Treatment should continue until symptoms have resolved and urine cultures no longer yield Candida species 2
- Diagnostic tests on urine often cannot differentiate colonization from infection, so symptoms guide treatment decisions 2
- Imaging (ultrasound or CT) may be helpful to rule out structural abnormalities, hydronephrosis, or fungus ball formation in patients with candiduria 2
Common Pitfalls to Avoid
- Treating asymptomatic candiduria in patients without risk factors for dissemination 2, 3, 6
- Using antifungal agents with poor urinary excretion (echinocandins, voriconazole) for lower urinary tract infections 2, 7, 4
- Overlooking the possibility of disseminated candidiasis in high-risk patients with candiduria 2, 3
- Failing to remove or replace indwelling catheters, which alone can resolve up to 50% of candiduria cases 4, 6
- Not considering that candiduria may represent colonization rather than infection in many cases 8, 6