What is the treatment for candidiasis with budding yeast-like cells in urine?

Treatment of Budding Yeast-Like Cells in Urine

For most patients with budding yeast cells in urine, no antifungal treatment is necessary—simply remove the urinary catheter if present and observe, as this represents colonization rather than infection in the majority of cases. 1

Initial Assessment: Determine if Treatment is Needed

The critical first step is distinguishing colonization from true infection, as approximately 50% of asymptomatic candiduria resolves spontaneously after removing predisposing factors. 2, 1

Mandatory treatment scenarios (even if asymptomatic):

• Neutropenic patients 1, 3
• Patients undergoing planned urologic procedures 1, 3
• Severely immunocompromised patients with fever 1
• Presence of urinary tract obstruction 1, 3
• Very low-birth-weight infants 4

Treatment indicated for symptomatic patients with:

• Urinary frequency, dysuria, or urgency (cystitis) 5
• Flank pain, fever, or systemic symptoms (pyelonephritis) 2
• Prostate tenderness or epididymal pain 2

First-Line Treatment Algorithm

For Symptomatic Cystitis

Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks is the treatment of choice for fluconazole-susceptible organisms. 2, 1, 5

Fluconazole is superior because it achieves high urinary concentrations in its active form, unlike other antifungals. 2, 1

For Symptomatic Pyelonephritis

Increase the dose to fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks. 2, 1

For Pre-Procedure Prophylaxis

Fluconazole 400 mg (6 mg/kg) daily for several days before and after urologic procedures. 1, 3

Treatment for Resistant Organisms

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. 2, 1

Alternative monotherapy: Oral flucytosine 25 mg/kg four times daily for 2 weeks (weaker recommendation). 2

C. krusei Infections

Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days. 2, 1

Bladder Irrigation for Resistant Cystitis

For refractory cystitis due to azole-resistant organisms, bladder irrigation with amphotericin B deoxycholate 50 mg/L sterile water daily for 5 days may be considered, though relapse rates are high. 2

Essential Non-Pharmacologic Interventions

Remove indwelling urinary catheters immediately if present—this alone resolves candiduria in approximately 50% of cases without antifungal therapy. 1, 3, 6

Address urinary tract obstruction—elimination of obstruction is strongly recommended as antifungals alone will fail without drainage. 2, 1

Remove or replace nephrostomy tubes/stents if feasible to improve treatment outcomes. 2

Critical Pitfalls to Avoid

Never use echinocandins (micafungin, caspofungin, anidulafungin) for Candida urinary tract infections—they achieve minimal urinary concentrations and are completely ineffective for lower tract infections. 2, 1, 5, 6

Avoid lipid formulations of amphotericin B—they do not achieve adequate urine concentrations and should not be used for urinary candidiasis. 2, 3

Do not use voriconazole or posaconazole—these azoles have poor urinary excretion and are ineffective for lower urinary tract infections. 2

Never treat asymptomatic candiduria in otherwise healthy patients—this leads to unnecessary antifungal exposure, potential resistance development, and does not prevent candidemia or other complications. 1, 5, 3

Special Clinical Scenarios

Fungus Balls

Surgical or endoscopic removal is mandatory, with adjunctive systemic fluconazole or amphotericin B deoxycholate therapy. 2, 1 Antifungal therapy alone will fail without mechanical debridement. 2

Candida Prostatitis/Epididymo-orchitis

Fluconazole is the agent of choice, with most patients requiring surgical drainage of abscesses in addition to antifungal therapy. 2, 1

Diabetic Patients

Apply the same treatment algorithm as above—diabetes alone does not mandate treatment of asymptomatic candiduria unless additional risk factors are present. 3

Treatment Duration and Monitoring

Continue therapy for 2 weeks for both cystitis and pyelonephritis, ensuring symptoms resolve and urine cultures are negative for Candida species. 2, 1, 5

For pyelonephritis, therapy should continue until lesions resolve on repeat imaging, which typically requires several months. 2

Species-Specific Considerations

C. albicans is typically fluconazole-susceptible and easily treated. 2, 5

C. glabrata accounts for approximately 20% of urine isolates and frequently requires alternative therapy due to fluconazole resistance. 2, 5

C. krusei is intrinsically fluconazole-resistant and requires amphotericin B. 2