What is the treatment for candida urinary tract infection (UTI)?

Treatment of Candida Urinary Tract Infection

For symptomatic Candida UTI with fluconazole-susceptible organisms, treat with oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks and remove any indwelling urinary catheter if present. 1

Initial Assessment and Risk Stratification

Before initiating treatment, distinguish between colonization and true infection, as most candiduria represents colonization that does not require antifungal therapy. 1, 2 Key factors indicating true infection include:

• Presence of symptoms (dysuria, urgency, frequency, flank pain, fever) 2, 3
• Clinical signs of pyelonephritis or systemic involvement 1
• Patients undergoing urologic procedures (treat prophylactically) 1, 4
• Neutropenic patients with fever and candiduria 1
• Very low birth weight neonates 1

Asymptomatic candiduria does not warrant treatment in most cases, as it represents colonization and treatment does not improve mortality. 1

Treatment Algorithm by Species and Clinical Presentation

For Cystitis (Lower UTI):

Fluconazole-susceptible species (C. albicans, most C. tropicalis, C. parapsilosis):

• Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks 1, 4
• Fluconazole is preferred due to high urinary concentrations, oral availability, and proven efficacy 4, 3

Fluconazole-resistant C. glabrata:

• Amphotericin B deoxycholate 0.3–0.6 mg/kg daily for 1–7 days, OR 1
• Oral flucytosine 25 mg/kg four times daily for 7–10 days 1, 4
• Amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) may be considered but has high recurrence rates 1

C. krusei:

• Amphotericin B deoxycholate 0.3–0.6 mg/kg daily for 1–7 days 1, 4

For Pyelonephritis (Upper UTI):

Fluconazole-susceptible organisms:

• Oral fluconazole 200–400 mg (3–6 mg/kg) daily for 2 weeks 1
• Higher doses are used for upper tract involvement 1

Fluconazole-resistant C. glabrata:

• Amphotericin B deoxycholate 0.3–0.6 mg/kg daily for 1–7 days, with or without oral flucytosine 25 mg/kg four times daily 1
• Monotherapy with oral flucytosine 25 mg/kg four times daily for 2 weeks is an alternative option 1

C. krusei:

• Amphotericin B deoxycholate 0.3–0.6 mg/kg daily for 1–7 days 1

Essential Non-Pharmacologic Interventions

Removal of indwelling bladder catheters is strongly recommended and often sufficient to clear candiduria without antifungal therapy. 1, 4 This intervention alone resolves candiduria in approximately 50% of asymptomatic patients. 5

Additional interventions include:

• Eliminate urinary tract obstruction (strongly recommended for pyelonephritis) 1
• Remove or replace nephrostomy tubes or stents if feasible 1, 6
• Discontinue unnecessary antibiotics 2

Periprocedural Prophylaxis

For patients undergoing urologic instrumentation with candiduria present:

• Oral fluconazole 400 mg (6 mg/kg) daily, OR 4
• Amphotericin B deoxycholate 0.3–0.6 mg/kg daily 4
• Administer for several days before and after the procedure to prevent candidemia 1, 4

Critical Pitfalls to Avoid

Do not use echinocandins (caspofungin, micafungin, anidulafungin) or other azoles besides fluconazole for lower urinary tract infections, as they achieve minimal urinary concentrations and are ineffective for Candida UTI. 6, 3, 5 While echinocandins may work for renal parenchymal infections despite poor urinary levels, clinical data is limited. 4

Do not use lipid formulations of amphotericin B, as they do not achieve adequate urine concentrations. 6

Do not rely on colony counts to differentiate colonization from infection, especially when catheters are present, as this distinction is unreliable. 4

Avoid bladder irrigation with amphotericin B as routine therapy, as it resolves candiduria in 80-90% initially but has high recurrence rates and limited long-term utility. 4, 3 It may be useful only for specific cases of fluconazole-resistant cystitis. 1

Monitoring and Follow-up

• Monitor for clinical improvement and symptom resolution 6
• Obtain follow-up urine cultures to confirm clearance of infection 6
• For persistent infection despite appropriate therapy, obtain imaging to rule out anatomical abnormalities, fungus balls, or obstruction 6, 3
• Continue treatment until symptoms resolve and urine cultures are negative for Candida 6