Should candida (fungal infection) in urine be treated?

From the Guidelines

Treatment for candida in urine (candiduria) is generally not recommended unless the patient belongs to a high-risk group, such as neutropenic patients, very low-birth-weight infants, or patients undergoing urologic procedures, in which case fluconazole or amphotericin B may be indicated. The decision to treat candiduria depends on the clinical situation and the presence of risk factors. Asymptomatic candiduria typically does not require treatment in most patients, especially those without risk factors, as it often represents colonization rather than infection 1. However, treatment is recommended for symptomatic patients, those with risk factors (immunocompromised status, diabetes, indwelling catheters), pregnant women, and patients undergoing urologic procedures.

When treatment is indicated, fluconazole is typically the first-line medication, usually given at 200-400mg daily for 7-14 days, as recommended by the Infectious Diseases Society of America 1. For fluconazole-resistant species, alternatives include amphotericin B bladder irrigation (50mg in 1L sterile water for 5-7 days) or oral flucytosine (25mg/kg four times daily for 7-10 days) 1. Removing or changing urinary catheters is essential when present, as catheters serve as a reservoir for fungal biofilms. Treatment is justified because persistent candiduria can lead to ascending infections, particularly in vulnerable patients.

Some key points to consider in the management of candiduria include:

• Elimination of predisposing factors, such as indwelling bladder catheters, is recommended whenever feasible 1
• Neutropenic patients and very low–birth-weight infants should be treated as recommended for candidemia 1
• Patients undergoing urologic procedures should be treated with oral fluconazole or AmB deoxycholate for several days before and after the procedure 1
• The presence of candida in urine often represents colonization rather than infection, which explains why asymptomatic cases in low-risk patients typically don't require antifungal therapy 1.

From the FDA Drug Label

For the treatment of Candida urinary tract infections and peritonitis, daily doses of 50 to 200 mg have been used in open, noncomparative studies of small numbers of patients. In open noncomparative studies of relatively small numbers of patients, fluconazole tablets were also effective for the treatment of Candida urinary tract infections, peritonitis, and systemic Candida infections including candidemia, disseminated candidiasis, and pneumonia.

Yes, you should treat candida in urine. The recommended dosage is 50 to 200 mg daily, as stated in the drug label 2 and 2.

From the Research

Treatment of Candida in Urine

• The presence of Candida species in urine does not always warrant antifungal therapy, especially in asymptomatic patients 3, 4, 5.
• Asymptomatic candiduria is usually benign and does not require local or systemic antifungal therapy, except in certain cases such as neutropenic patients, very low-birth-weight infants, and patients undergoing urologic procedures 3, 4.
• Treatment of symptomatic candiduria is less controversial and easier, with fluconazole being the antifungal agent of choice due to its high urine concentrations and oral formulation 3, 5, 6.
• Other treatment options, such as amphotericin B and flucytosine, may be used in certain cases, but their use requires caution due to toxicity and other factors 5, 6.
• Removing predisposing factors, such as indwelling catheters and antibiotics, can clear candiduria in almost 50% of asymptomatic patients 5.
• The role of echinocandins and azoles that do not achieve measurable concentrations in the urine is not clear, and their use is not recommended for the treatment of urinary tract infections 5, 6.

Risk Factors and Diagnosis

• Risk factors for candiduria include urinary indwelling catheters, use of antibiotics, elderly age, underlying genitourinary tract abnormality, previous surgery, and presence of diabetes mellitus 4, 7.
• Candiduria may represent only colonization, and there are no consistent diagnostic criteria to define significant infection 4.
• Physicians need to confirm the infection by a second sterile urine sample and adopt non-pharmacologic interventions to modify risk factors 4.
• Awareness to validate candiduria is necessary to stratify treatment according to patient status, and appropriate use of antifungal drugs should not replace correction of underlying risk factors 4.