Treatment of Candida parapsilosis in a Patient with a Foley Catheter
Remove the Foley catheter immediately and initiate systemic antifungal therapy—catheter removal is mandatory for all Candida urinary tract infections, and catheter retention consistently worsens outcomes. 1, 2, 3
Immediate Catheter Management
Remove the catheter as soon as possible, as this is the single most important intervention for candiduria and has been shown to improve outcomes across all prospective studies. 1, 2, 3
Send the catheter tip for culture to confirm the source of infection and guide ongoing management. 2, 3
Do not attempt catheter retention or exchange over a guidewire in this scenario—while guidewire exchange may be considered in catheter-related bloodstream infections with extremely limited venous access, this does not apply to urinary catheters where removal is straightforward. 3
Catheter removal alone results in eradication of candiduria in approximately 40% of patients, but systemic antifungal therapy is still required. 1
Systemic Antifungal Therapy
Initiate fluconazole 200-400 mg daily (or 6 mg/kg/day) for 14 days, as this is the antifungal agent of choice for Candida urinary tract infections, achieving high urine concentrations with oral formulation. 1, 4, 5
Specific Considerations for C. parapsilosis:
C. parapsilosis is fully susceptible to fluconazole, making it the preferred agent for this species in urinary tract infections. 1, 5, 6
While C. parapsilosis may have higher MICs to echinocandins compared to other Candida species, this is primarily relevant in bloodstream infections, not urinary tract infections where fluconazole achieves superior urinary concentrations. 1, 7
Echinocandins are NOT recommended for urinary tract infections because they fail to achieve adequate urine concentrations, despite being effective for bloodstream infections. 5
Alternative Agents (if fluconazole cannot be used):
Amphotericin B deoxycholate 0.3-0.6 mg/kg/day IV can be used, though it has significant nephrotoxicity concerns. 1
Flucytosine 25 mg/kg orally four times daily is an alternative option. 1
Amphotericin B bladder irrigation is NOT recommended as it fails to treat disease above the level of the bladder. 1
Duration of Therapy
Treat for 14 days after catheter removal and initiation of antifungal therapy. 1, 3
A placebo-controlled trial demonstrated that fluconazole 200 mg/day for 14 days hastened time to negative urine culture, with approximately 73% of non-catheterized patients achieving negative cultures. 1
Monitoring and Follow-up
Obtain blood cultures to rule out candidemia, especially in high-risk patients (neutropenic, critically ill, transplant recipients, low birth weight infants). 1, 2
Candiduria in these high-risk populations may be a marker of disseminated candidiasis and requires more aggressive evaluation. 1
Repeat urine culture 48-72 hours after initiating therapy to document clearance. 3
Critical Pitfalls to Avoid
Never leave the catheter in place while treating candiduria—this approach has been shown to result in clearance in less than 20% of cases and is associated with worse outcomes. 1
Never treat asymptomatic candiduria in catheterized patients without removing the catheter first—antimicrobial therapy while the catheter remains in place leads to evolution of resistant flora without clinical benefit. 8
Do not use echinocandins for urinary tract infections—despite their effectiveness in bloodstream infections, they do not achieve adequate urinary concentrations. 5
Be aware that C. parapsilosis peritonitis and catheter-related bloodstream infections have higher complication rates (78% vs 20% for other Candida species) and may require more aggressive management, but this does not apply to simple urinary tract infections. 9