What is the treatment for candida in urine culture?

Treatment of Candida in Urine Culture

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

Initial Assessment: Determine if Treatment is Needed

Not all candiduria requires antifungal therapy—most cases represent colonization or catheter contamination rather than true infection. 1, 2

Treatment is indicated for:

• Symptomatic cystitis (dysuria, frequency, urgency, suprapubic pain) 1, 3
• Pyelonephritis (fever, flank pain, systemic symptoms) 1
• Neutropenic patients (even if asymptomatic) 1, 4
• Patients undergoing urologic procedures 1, 4
• Very low-birth-weight infants 2
• Severely immunocompromised patients with fever 4

Treatment is NOT indicated for:

• Asymptomatic candiduria in otherwise healthy patients 1, 4, 5
• Catheter-associated candiduria without symptoms 1

First-Line Management: Remove Predisposing Factors

Before initiating antifungals, remove the indwelling bladder catheter if feasible—this alone resolves candiduria in approximately 50% of asymptomatic patients. 1, 4, 6 This represents the critical first step and may eliminate the need for antifungal therapy entirely. 4

Treatment Algorithm by Clinical Scenario

Symptomatic Cystitis

For fluconazole-susceptible organisms (C. albicans, most C. tropicalis, C. parapsilosis):

• Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks 1, 3, 5
• Fluconazole is preferred because it achieves high urinary concentrations in active form and is available orally 1, 2

For fluconazole-resistant C. glabrata:

• Amphotericin B deoxycholate 0.3–0.6 mg/kg daily for 1–7 days 1
• 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 useful as adjunctive therapy 1

For C. krusei (intrinsically fluconazole-resistant):

• Amphotericin B deoxycholate 0.3–0.6 mg/kg daily for 1–7 days 1

Pyelonephritis

For fluconazole-susceptible organisms:

• Oral fluconazole 200–400 mg (3–6 mg/kg) daily for 2 weeks 1, 5

For 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 four times daily 1
• Monotherapy with oral flucytosine 25 mg/kg four times daily for 2 weeks is a weaker alternative 1

For C. krusei:

• Amphotericin B deoxycholate 0.3–0.6 mg/kg daily for 1–7 days 1

Eliminate urinary tract obstruction if present—this is essential for treatment success. 1

Pre-Procedure Prophylaxis

For patients undergoing urologic procedures with candiduria:

• Oral fluconazole 400 mg (6 mg/kg) daily for several days before and after the procedure 1, 4
• OR Amphotericin B deoxycholate 0.3–0.6 mg/kg daily for several days before and after the procedure 1

Fungus Balls

Surgical or endoscopic removal is mandatory—antifungals alone are insufficient. 1, 5

• Systemic antifungal therapy as noted above for cystitis or pyelonephritis 1
• Irrigation through nephrostomy tubes with Amphotericin B deoxycholate 25–50 mg in 200–500 mL sterile water as adjunctive therapy 1

Species-Specific Considerations

C. albicans (most common, ~60% of isolates) is typically fluconazole-susceptible. 7, 8

C. glabrata (second most common, ~20% of isolates) frequently demonstrates fluconazole resistance and requires alternative therapy. 1, 8

C. krusei is intrinsically resistant to fluconazole and always requires amphotericin B. 1

C. tropicalis and C. parapsilosis are usually fluconazole-susceptible. 8

Critical Pitfalls to Avoid

Do not use echinocandins (caspofungin, micafungin, anidulafungin) for lower urinary tract infections—they achieve minimal urinary concentrations and are ineffective despite adequate tissue levels. 1, 5, 6 While there are case reports of success for renal parenchymal infections, failures are common and these agents are not recommended. 1

Do not use lipid formulations of amphotericin B for Candida UTI—they do not achieve adequate urine concentrations and treatment failures are well-documented. 1, 3

Do not use voriconazole or other azoles (besides fluconazole) for lower UTI—they have poor urinary excretion. 1, 5

Do not treat asymptomatic candiduria in otherwise healthy patients—this represents colonization, and treatment does not prevent complications or candidemia. 1, 4, 5

Do not overlook the possibility of disseminated candidiasis in high-risk patients—if candiduria occurs with candidemia or suspected disseminated disease, treat as candidemia (not as isolated UTI). 1, 3

Monitoring and Follow-Up

Continue therapy until symptoms resolve and urine cultures are negative for Candida species. 3, 5 The standard duration is 2 weeks for both cystitis and pyelonephritis. 1, 3, 5

Bladder irrigation with amphotericin B resolves candiduria in 80–90% of patients initially, but relapse rates are very high—this approach is generally discouraged except for refractory cystitis due to azole-resistant organisms. 1