What is the treatment for yeast in urine?

Treatment of Yeast in Urine

For asymptomatic candiduria, treatment is generally not recommended unless the patient is at high risk for dissemination (neutropenic, neonate with low birth weight, or undergoing urologic procedures). 1 For symptomatic candiduria, fluconazole 200 mg (3 mg/kg) daily for 2 weeks is the first-line treatment. 1, 2

Clinical Decision Algorithm

Step 1: Determine if Treatment is Needed

Asymptomatic candiduria (no urinary symptoms):

• Do NOT treat in most patients—observation alone is appropriate 1, 3
• Removing predisposing factors (especially indwelling catheters) clears candiduria in approximately 50% of cases without antifungal therapy 1, 4

High-risk patients requiring treatment even when asymptomatic: 1, 3

• Neutropenic patients (treat as disseminated candidiasis)
• Neonates with low birth weight (treat as disseminated candidiasis)
• Patients undergoing urologic procedures (fluconazole 200-400 mg daily or amphotericin B deoxycholate 0.3-0.6 mg/kg daily for several days before and after the procedure)

Symptomatic candiduria (dysuria, frequency, urgency):

• Always treat 1, 2

Step 2: Identify the Clinical Syndrome

Symptomatic cystitis (lower urinary tract symptoms): 1

• Fluconazole 200 mg (3 mg/kg) daily for 2 weeks for fluconazole-susceptible species
• Alternative for fluconazole-resistant organisms: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days OR flucytosine 25 mg/kg four times daily for 7-10 days

Pyelonephritis (flank pain, fever, upper tract symptoms): 1

• Fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks for susceptible organisms
• Alternative for resistant strains: Amphotericin B deoxycholate 0.5-0.7 mg/kg daily with or without flucytosine 25 mg/kg four times daily for 2 weeks
• If disseminated candidiasis is suspected, treat as candidemia 1

Fungus balls (urinary obstruction, imaging findings): 1

• Surgical removal is strongly recommended in non-neonates
• Adjunctive systemic therapy: Fluconazole 200-400 mg (3-6 mg/kg) daily OR amphotericin B deoxycholate 0.5-0.7 mg/kg daily with or without flucytosine
• Local irrigation with amphotericin B (50 mg/L sterile water) may be used as adjunct if access to renal collecting system is available

Step 3: Consider Species and Resistance Patterns

Fluconazole-susceptible species (most C. albicans): 2, 5

• Fluconazole is the drug of choice, achieving excellent urinary concentrations 6, 4

Fluconazole-resistant species (C. glabrata, C. krusei): 1, 2

• Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for cystitis OR 0.5-0.7 mg/kg daily for pyelonephritis
• Flucytosine 25 mg/kg four times daily (requires therapeutic drug monitoring with target levels 40-60 mg/mL) 7
• Amphotericin B bladder irrigation may be considered for refractory cases 1

Critical Pitfalls to Avoid

Do not use echinocandins or voriconazole for urinary tract infections: 2, 4

• These agents achieve minimal urinary excretion and are ineffective for Candida UTI

Do not use lipid formulations of amphotericin B for urinary infections: 2

• They do not achieve adequate urine concentrations; only amphotericin B deoxycholate is appropriate

Do not treat asymptomatic candiduria in low-risk patients: 1, 3, 5

• This leads to unnecessary antifungal exposure, potential resistance, and adverse effects without clinical benefit

Do not use flucytosine as monotherapy: 7

• Rapid emergence of resistance occurs; always combine with amphotericin B when using flucytosine

Do not overlook disseminated candidiasis in high-risk patients: 2, 3

• Neutropenic patients with fever and candiduria require treatment for presumed disseminated disease, not just urinary infection

Treatment Duration

• Standard duration: 2 weeks for cystitis and pyelonephritis 1, 2
• Continue treatment until symptoms resolve and urine cultures no longer yield Candida species 1, 2
• For fungus balls, treat until symptoms resolve and cultures clear 1