What are the treatment requirements for symptomatic candiduria?

Treatment Requirements for Symptomatic Candiduria

For symptomatic Candida cystitis, treat with oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks if the organism is fluconazole-susceptible. 1

Initial Assessment and Risk Stratification

Before initiating treatment, you must determine whether candiduria represents true infection versus colonization:

• Symptomatic candiduria requires treatment when patients have urinary frequency, dysuria, urgency, or suprapubic pain with positive urine cultures 1, 2
• Confirm infection with a second sterile urine sample to eliminate contamination before committing to antifungal therapy 3, 4
• Remove indwelling urinary catheters immediately if feasible, as this alone clears candiduria in approximately 50% of cases and is the most important initial intervention 1, 5

Treatment Algorithm by Clinical Presentation

Symptomatic Cystitis (Lower UTI)

First-line therapy:

• Fluconazole 200 mg (3 mg/kg) orally daily for 2 weeks for fluconazole-susceptible species (C. albicans, most C. parapsilosis, C. tropicalis) 1, 2
• Fluconazole achieves excellent urinary concentrations and is the preferred agent for most Candida UTIs 6

For fluconazole-resistant organisms (C. glabrata, C. krusei):

• Amphotericin B deoxycholate 0.3-0.6 mg/kg IV daily for 1-7 days 1
• Oral flucytosine 25 mg/kg four times daily for 7-10 days as an alternative 1
• Amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) may be useful specifically for fluconazole-resistant species like C. glabrata and C. krusei 1

Candida Pyelonephritis (Upper UTI)

For fluconazole-susceptible organisms:

• Fluconazole 200-400 mg (3-6 mg/kg) orally daily for 2 weeks 1

For fluconazole-resistant strains (especially C. glabrata):

• Amphotericin B deoxycholate 0.5-0.7 mg/kg IV daily with or without flucytosine 25 mg/kg four times daily for 2 weeks 1, 3
• Flucytosine alone 25 mg/kg four times daily for 2 weeks is an alternative 1

Fungus Balls (Renal or Bladder)

• Surgical intervention is strongly recommended as the primary treatment in non-neonates 1
• Fluconazole 200-400 mg (3-6 mg/kg) daily as adjunctive systemic therapy 1
• Amphotericin B irrigation (50 mg/L sterile water) if access to the renal collecting system is available 1
• Continue treatment until symptoms resolve and urine cultures are negative for Candida 1

Suspected Disseminated Candidiasis

• Treat as candidemia with echinocandins or other systemic antifungals per candidemia guidelines 1

Critical Pitfalls to Avoid

Do not use echinocandins for urinary tract infections:

• Caspofungin, micafungin, and anidulafungin achieve minimal urinary concentrations and are generally ineffective for Candida UTI 2, 5
• While rare case reports describe success with high-dose micafungin (150 mg daily) for C. krusei UTI in transplant patients, this is not standard practice 7

Do not use lipid formulations of amphotericin B for UTI:

• Liposomal amphotericin B and amphotericin B lipid complex do not achieve adequate urine concentrations 2
• Only amphotericin B deoxycholate is appropriate for urinary tract infections 1

Do not use voriconazole or other newer azoles:

• These agents have poor urinary excretion and are ineffective for lower urinary tract infections 2, 5

Do not treat asymptomatic candiduria in low-risk patients:

• Asymptomatic candiduria rarely leads to candidemia (<5%) and treatment does not improve mortality 1, 6
• Overtreatment of asymptomatic candiduria is common and inappropriate 8

Special Populations Requiring Treatment Despite Being Asymptomatic

High-risk patients who require treatment even without symptoms include:

• Neutropenic patients - manage as invasive candidiasis 1, 6
• Infants with very low birth weight - at high risk for invasive candidiasis involving the urinary tract 1, 6
• Patients undergoing urologic procedures - fluconazole 200-400 mg (3-6 mg/kg) daily or amphotericin B deoxycholate 0.3-0.6 mg/kg daily for several days before and after the procedure 1, 6
• Severely immunocompromised patients with fever and candiduria 6

Species-Specific Considerations

• C. albicans is typically fluconazole-susceptible and responds well to standard therapy 2
• C. glabrata often exhibits fluconazole resistance and requires amphotericin B or flucytosine 1, 2
• C. krusei has intrinsic fluconazole resistance and requires amphotericin B deoxycholate 0.3-0.6 mg/kg daily 1

Treatment Duration and Monitoring

• Standard duration is 2 weeks for cystitis 1, 2
• Continue treatment until symptoms resolve and repeat urine cultures are negative for Candida 1, 2
• For pyelonephritis, treat for 2 weeks with appropriate agents based on susceptibility 1