When is treatment for candida urinary tract infection (UTI) recommended?

When to Treat Candida UTI

Treat candida UTI only when patients have symptomatic infection (cystitis or pyelonephritis) or belong to high-risk groups, as asymptomatic candiduria represents colonization in most cases and does not require antifungal therapy. 1

High-Risk Patients Requiring Treatment (Even if Asymptomatic)

The following patient populations warrant antifungal treatment even without urinary symptoms 1:

• Neutropenic patients - treat as invasive candidiasis 1
• Very low birth weight infants 1
• Patients undergoing urologic procedures or instrumentation - administer fluconazole 200-400 mg (3-6 mg/kg) daily or amphotericin B 0.3-0.6 mg/kg daily for several days before and after the procedure 1
• Patients with urinary tract obstruction 1
• Transplant recipients 1
• Critically ill ICU patients (though evidence shows empiric antifungal therapy may actually worsen outcomes in ICU patients with candiduria and no other source) 1

Symptomatic Infections Requiring Treatment

Cystitis (Lower UTI)

Treat when patients present with dysuria, urgency, frequency, or suprapubic pain with positive urine culture 1:

• Fluconazole-susceptible species: Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks 1
• Fluconazole-resistant C. glabrata: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days OR oral flucytosine 25 mg/kg 4 times daily for 7-10 days 1
• C. krusei: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1
• Remove indwelling bladder catheter if feasible - this is strongly recommended and resolves candiduria in approximately 40% of non-catheterized patients 1

Pyelonephritis (Upper UTI)

Treat when patients have fever, flank pain, costovertebral angle tenderness with positive urine culture 1:

• Fluconazole-susceptible species: Oral fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks 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 4 times daily, OR flucytosine monotherapy 25 mg/kg 4 times daily for 2 weeks 1
• C. krusei: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1
• Eliminate urinary tract obstruction - strongly recommended; consider removal or replacement of nephrostomy tubes or stents if feasible 1

Do NOT Treat Asymptomatic Candiduria in Standard-Risk Patients

Asymptomatic candiduria in non-neutropenic, catheterized patients without planned urologic procedures does not require treatment 1. Key evidence:

• A placebo-controlled trial showed fluconazole hastened time to negative culture, but 2 weeks after therapy ended, clearance rates were identical between treatment and placebo groups (~60% for catheterized, ~73% for non-catheterized patients) 1
• Removing predisposing factors (catheters, antibiotics) clears candiduria in approximately 40-50% of asymptomatic patients without antifungal therapy 1, 2, 3
• Treatment of asymptomatic candiduria has never been shown to provide clinical benefit in standard-risk patients 1

Critical Diagnostic Considerations

Before treating, confirm true infection versus colonization/contamination 1:

• Obtain second urine culture to eliminate contamination before initiating therapy 2
• Pyuria cannot differentiate infection from colonization, especially with indwelling catheters 1
• Colony count is unreliable for distinguishing infection from colonization when catheters are present 1
• Imaging (ultrasound/CT) is helpful for identifying structural abnormalities, hydronephrosis, abscesses, or fungus balls that require surgical intervention 1
• Consider candidemia - if suspected disseminated infection, treat as candidemia rather than isolated UTI 1

Common Pitfalls to Avoid

• Do not use echinocandins or newer azoles (voriconazole, posaconazole) for candida UTI - they fail to achieve adequate urine concentrations 3, 4
• Do not routinely use amphotericin B bladder irrigation - it only treats disease at bladder level, not upper tract; reserve for fluconazole-resistant cystitis when systemic therapy cannot be used 1
• Do not treat candiduria simply because it is present - only 4-14% of patients with candiduria have true symptomatic infection 2
• Avoid empiric antifungal therapy in ICU patients with candiduria alone - retrospective data shows this may increase mortality (OR 3.24) without improving outcomes 1