When should yeast infections be treated in patients?

Indications to Treat Yeast in Urine (Candiduria)

Asymptomatic candiduria does NOT require treatment in most patients; treatment is indicated ONLY for high-risk groups including neonates, neutropenic adults, and patients undergoing urologic procedures. 1

Risk Stratification for Treatment Decision

DO NOT TREAT - Asymptomatic Candiduria

• Immunocompetent patients with asymptomatic candiduria (yeast in urine without symptoms) should NOT receive antifungal therapy 1
• The primary intervention is elimination of predisposing factors (remove urinary catheters, discontinue unnecessary antibiotics, control hyperglycemia) 1

TREAT - High-Risk Asymptomatic Patients

Treatment is indicated for asymptomatic candiduria in:

• Neonates 1
• Neutropenic adults 1
• Patients undergoing urologic procedures (treat several days before and after the procedure) 1

For these high-risk asymptomatic patients:

• Treat as for disseminated candidiasis 1
• For perioperative prophylaxis: Fluconazole 200-400 mg (3-6 mg/kg) daily OR amphotericin B deoxycholate 0.3-0.6 mg/kg daily for several days before and after the urologic procedure 1

TREAT - Symptomatic Cystitis

All patients with symptomatic candiduria (dysuria, frequency, urgency, suprapubic pain) require treatment 1

First-line therapy:

• Fluconazole 200 mg (3 mg/kg) daily for 2 weeks 1

Alternative therapy for fluconazole-resistant organisms (C. krusei, C. glabrata):

• Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1
• Flucytosine 25 mg/kg four times daily for 7-10 days 1
• Amphotericin B bladder irrigation is reserved ONLY for refractory fluconazole-resistant organisms 1

TREAT - Pyelonephritis

All patients with Candida pyelonephritis require systemic antifungal therapy 1

First-line therapy:

• Fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks 1

Alternative therapy:

• Amphotericin B deoxycholate 0.5-0.7 mg/kg daily with or without flucytosine 25 mg/kg four times daily for 2 weeks 1
• Flucytosine alone for 2 weeks 1

Critical consideration: If pyelonephritis with suspected disseminated candidiasis, treat as for candidemia with longer duration and higher doses 1

Special Populations

Immunocompromised Patients on Corticosteroids

• Pyuria (positive leukocytes) combined with Candida on microscopy indicates active infection requiring treatment, not colonization 2
• Fluconazole 800 mg loading dose, then 400 mg daily is recommended for immunocompromised patients without recent azole exposure 2
• Continue therapy throughout periods of immunosuppression to prevent relapse 2

Critically Ill ICU Patients

• Empiric antifungal therapy should be considered in critically ill patients with risk factors for invasive candidiasis and no other known cause of fever 1, 3
• Echinocandins are preferred (anidulafungin 200 mg loading, then 100 mg daily; micafungin 100 mg daily; caspofungin 70 mg loading, then 50 mg daily) for septic shock or recent azole exposure 1, 3
• Fluconazole 800 mg loading, then 400 mg daily is acceptable for hemodynamically stable patients without azole exposure 1, 3

Common Pitfalls to Avoid

• Do NOT treat asymptomatic candiduria in catheterized patients - remove the catheter instead 1
• Do NOT use bladder irrigation as first-line therapy - it is reserved only for refractory fluconazole-resistant organisms 1
• Do NOT assume all candiduria represents infection - distinguish colonization from true infection based on symptoms and host factors 1, 2
• Do NOT delay treatment in symptomatic or high-risk patients - mortality increases with delayed therapy 1, 3
• Do NOT prematurely discontinue therapy in immunocompromised patients - this leads to relapse 2
• Always obtain blood cultures if systemic symptoms develop to rule out candidemia 2
• Perform imaging (CT or ultrasound) of genitourinary tract if blood cultures remain positive to assess for complications 1