What is the treatment for a urinary tract infection with pus cells and budding yeasts present in the urine?

Treatment of Candida Urinary Tract Infection

For symptomatic Candida UTI with pus cells and budding yeasts, treat with oral fluconazole 200 mg daily for 2 weeks, assuming fluconazole-susceptible species. 1

Initial Assessment

The presence of pus cells (pyuria) alongside budding yeasts indicates symptomatic infection rather than mere colonization, warranting antifungal treatment. 1 However, you must first determine:

• Remove or address predisposing factors immediately - particularly indwelling urinary catheters, which should be removed if feasible, as this alone resolves candiduria in nearly 50% of cases 1, 2
• Assess infection severity - determine if this is cystitis (lower tract) versus pyelonephritis (upper tract) based on fever, flank pain, and systemic symptoms 1
• Identify the patient's risk status - neutropenia, diabetes, recent broad-spectrum antibiotics, ICU admission, or urinary obstruction 3

First-Line Treatment Algorithm

For Presumed Fluconazole-Susceptible Species (Most Common)

Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks is the treatment of choice for symptomatic cystitis. 1, 4 This recommendation is based on:

• Fluconazole achieves exceptionally high urinary concentrations in its active form 1
• Candida albicans, the most common urinary pathogen, is typically fluconazole-susceptible 4
• It was proven effective in the only randomized, double-blind, placebo-controlled trial for candiduria 1
• Available as oral formulation, making outpatient treatment feasible 5

If pyelonephritis is suspected (fever, flank pain, systemic symptoms), increase the dose to fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks. 1

Alternative Regimens for Resistant Species

For Fluconazole-Resistant C. glabrata

If the patient has prior fluconazole exposure, is critically ill, or culture identifies C. glabrata:

• 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 (cystitis) or 2 weeks (pyelonephritis) 1
• Flucytosine monotherapy risks rapid resistance emergence, so reserve for situations where amphotericin B cannot be used 6

For C. krusei

Amphotericin B deoxycholate 0.3-0.6 mg/kg IV daily for 1-7 days is required, as C. krusei is intrinsically fluconazole-resistant. 1

Critical Management Principles

Address structural abnormalities aggressively:

• Eliminate urinary tract obstruction immediately - this is as important as antifungal therapy 1
• Consider imaging (ultrasound or CT) to rule out hydronephrosis, abscesses, or fungus ball formation 1, 4
• Remove or replace nephrostomy tubes/stents if present 1

Common Pitfalls to Avoid

Do NOT use these agents for Candida UTI:

• Echinocandins (caspofungin, micafungin, anidulafungin) - minimal urinary excretion, generally ineffective 1, 2
• Lipid formulations of amphotericin B - inadequate urine concentrations 1, 4
• Other azoles besides fluconazole (voriconazole, itraconazole, posaconazole) - poor urinary penetration 1, 4

Avoid treating asymptomatic candiduria unless the patient is neutropenic, a very low-birth-weight infant, or undergoing urologic procedures. 1, 4 In these high-risk groups, treat prophylactically with fluconazole 200-400 mg daily or amphotericin B 0.3-0.6 mg/kg daily for several days before and after procedures. 1

Bladder irrigation with amphotericin B (50 mg/L sterile water daily for 5 days) is generally discouraged but may be considered for fluconazole-resistant cystitis when systemic therapy fails. 1 This approach has high recurrence rates and requires an indwelling catheter. 1

Special Considerations

If fungus balls are suspected (obstruction, imaging findings), surgical or endoscopic removal is mandatory - antifungal therapy alone will fail. 1 Combine surgical intervention with systemic antifungal therapy as outlined above. 1

For disseminated candidiasis with renal involvement (hematogenous spread), treat as candidemia rather than isolated UTI - this requires higher doses and potentially echinocandins. 1