When is treatment indicated for candiduria?

Treatment Indications for Candiduria

Treatment of asymptomatic candiduria is NOT recommended for most patients, as it represents colonization rather than infection and does not improve mortality or morbidity outcomes. 1

High-Risk Patients Requiring Treatment

Treatment is indicated for asymptomatic candiduria in the following specific populations:

• Neutropenic patients with fever and candiduria, as this may indicate invasive candidiasis 1
• Very low birth weight infants who are at risk for invasive candidiasis involving the urinary tract 1
• Patients undergoing urologic procedures or instrumentation, due to documented high rates of candidemia following manipulation 1
• Patients with urinary tract obstruction, where candiduria may lead to ascending infection 1

For patients undergoing urologic procedures, administer 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 procedure. 1

Symptomatic Infections Requiring Treatment

Candida Cystitis

For symptomatic cystitis with fluconazole-susceptible species, oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks is the treatment of choice. 1

• For fluconazole-resistant organisms (C. glabrata, C. krusei), use amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days OR oral flucytosine 25 mg/kg four times daily for 7-10 days 1
• Amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) may be considered for fluconazole-resistant species, though this is generally not recommended as first-line 1

Candida Pyelonephritis

For pyelonephritis with fluconazole-susceptible organisms, oral fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks is recommended. 1

• For fluconazole-resistant strains, alternatives include amphotericin B deoxycholate 0.5-0.7 mg/kg daily with or without flucytosine 25 mg/kg four times daily, or flucytosine monotherapy at 25 mg/kg four times daily for 2 weeks 1

Fungus Balls

Surgical intervention is strongly recommended for fungus balls in non-neonates, combined with systemic antifungal therapy. 1

• Fluconazole 200-400 mg (3-6 mg/kg) daily is recommended as adjunctive therapy 1
• If access to the renal collecting system is available, irrigation with amphotericin B 50 mg/L sterile water can be used as an adjunct 1
• Continue treatment until symptoms resolve and urine cultures no longer yield Candida species 1

Suspected Disseminated Candidiasis

If candiduria is associated with suspected disseminated candidiasis, treat as candidemia with appropriate systemic antifungal therapy. 1

First-Line Management: Catheter Removal

Removal of indwelling urinary catheters is strongly recommended and often sufficient to eradicate candiduria without antifungal therapy. 1

• Catheter removal alone results in eradication of candiduria in approximately 40% of patients 1
• This should be the first intervention before considering antifungal therapy in asymptomatic patients 1, 2
• Multiple studies demonstrate that candiduria is a marker for severity of underlying illness rather than a cause of mortality, and treatment does not change mortality rates 1, 2

Important Clinical Considerations

Candiduria rarely progresses to candidemia (<5% of cases), even in high-risk populations. 1, 3

• A placebo-controlled trial demonstrated that fluconazole hastened clearance of candiduria, but 2 weeks after treatment completion, clearance rates were identical between treated and untreated groups (approximately 60% for catheterized patients and 73% for non-catheterized patients) 1
• This evidence strongly supports the recommendation against treating asymptomatic candiduria in most patients 1

Common Pitfalls to Avoid

• Do not treat asymptomatic candiduria in non-neutropenic catheterized patients, as this has never been shown to provide benefit and may select for resistant organisms 1
• Do not use echinocandins for urinary tract infections, as they do not achieve adequate urinary concentrations 1, 4, 5
• Do not overlook the possibility of disseminated candidiasis in high-risk patients (neutropenic, transplant recipients, critically ill ICU patients) with candiduria, as this may be a marker of systemic infection 1, 3