Treatment of Candida Non-Albicans in Urine
Candida non-albicans in urine does NOT require treatment if the patient is asymptomatic, but DOES require treatment if the patient has symptoms of cystitis/pyelonephritis, is neutropenic, is undergoing urologic procedures, or has specific high-risk conditions. 1
Clinical Decision Algorithm
Step 1: Determine if Treatment is Indicated
Do NOT treat if:
- Patient is asymptomatic without risk factors 1
- Candiduria resolves spontaneously in 76% of untreated cases 1
DO treat if any of the following:
- Symptomatic cystitis (dysuria, frequency, urgency) 1, 2
- Symptomatic pyelonephritis (fever, flank pain) 1
- Neutropenic patients with persistent fever 3
- Patients undergoing urologic procedures/manipulations 3
- Very low birth weight infants 3
- Urinary tract obstruction present 1
Step 2: Remove Predisposing Factors FIRST
Catheter removal is the single most important intervention:
- Remove indwelling bladder catheter if feasible (strong recommendation) 1
- Catheter removal alone resolves candiduria in approximately 50% of cases 4, 5
- This should be done before or concurrent with antifungal therapy 1
Address urinary obstruction:
- Eliminate obstruction (strong recommendation) 1
- Remove or replace nephrostomy tubes/stents if feasible 1
Step 3: Identify the Candida Species and Susceptibility
Critical species-specific considerations:
- C. glabrata: Often fluconazole-resistant, requires alternative therapy 1, 4
- C. krusei: Intrinsically fluconazole-resistant 1, 6
- C. albicans: Usually fluconazole-susceptible 1, 4
Treatment Recommendations by Clinical Scenario
For Symptomatic Cystitis with Fluconazole-Susceptible Species
First-line therapy:
- Fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks 1, 2
- Fluconazole achieves excellent urinary concentrations and is the drug of choice 1, 7
For Fluconazole-Resistant C. glabrata
Recommended options:
- Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days, with or without oral flucytosine 25 mg/kg 4 times daily 1
- Alternative: Oral flucytosine monotherapy 25 mg/kg 4 times daily for 2 weeks (weak recommendation) 1
- Amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) may be useful for resistant cystitis 1
For C. krusei (Intrinsically Fluconazole-Resistant)
Recommended therapy:
- Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1
- Amphotericin B bladder irrigation as adjunctive therapy if needed 1
For Symptomatic Pyelonephritis
Treatment approach:
- Fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks for susceptible organisms 1, 3
- For resistant species: Amphotericin B deoxycholate 0.5-0.7 mg/kg/day with or without flucytosine 4
- Continue until symptoms resolve and imaging abnormalities clear 1
Special Considerations for Non-Albicans Species
Important pharmacologic limitations:
- Echinocandins (caspofungin, micafungin, anidulafungin) achieve poor urinary concentrations and are NOT recommended for isolated lower UTI 1, 7
- However, emerging evidence suggests micafungin may have some efficacy despite low urine levels 6, 8
- Lipid formulations of amphotericin B do NOT achieve adequate urine concentrations and should be avoided for isolated UTI 1, 9
- Other azoles (voriconazole, posaconazole) have minimal urinary excretion 5
Only amphotericin B deoxycholate, fluconazole, and flucytosine achieve adequate urinary concentrations 1, 7, 5
Critical Pitfalls to Avoid
Common errors in management:
- Treating asymptomatic candiduria in low-risk patients—this provides no benefit and promotes resistance 1, 3
- Using echinocandins or non-fluconazole azoles for lower UTI—these fail to achieve therapeutic urine levels 2, 5
- Failing to remove urinary catheters—this is often more important than antifungal therapy 1
- Missing disseminated candidiasis in high-risk patients—obtain imaging if blood cultures remain positive 2, 3
- Using lipid amphotericin B formulations for isolated UTI—only deoxycholate formulation works 1, 9
Diagnostic considerations: