Treatment of Occasional Yeast Budding in Urine
For occasional yeast budding in urine without symptoms, treatment is not recommended—observation alone is appropriate unless the patient has specific high-risk features. 1
When Treatment is NOT Indicated
Asymptomatic candiduria (including occasional yeast budding on microscopy) does not require antifungal therapy in most patients. 1, 2
Elimination of predisposing factors alone—such as removing indwelling urinary catheters, discontinuing broad-spectrum antibiotics, or optimizing diabetes control—resolves candiduria in approximately 50% of cases without any antifungal treatment. 1, 2, 3
The presence of yeast in urine typically represents colonization or contamination rather than true infection, and treating asymptomatic candiduria leads to unnecessary antifungal exposure and potential resistance development without preventing candidemia. 2, 4
High-Risk Patients Who Require Treatment Despite Being Asymptomatic
Treatment is warranted for asymptomatic candiduria only in these specific populations:
- Neutropenic patients (manage as invasive candidiasis) 1
- Very low-birth-weight infants (manage as invasive candidiasis) 1, 4
- Patients undergoing urologic procedures or manipulation (fluconazole 200-400 mg daily or amphotericin B deoxycholate 0.3-0.6 mg/kg daily for several days before and after the procedure) 1, 2
If Symptoms Develop: Treatment Algorithm
Should the patient develop urinary symptoms (dysuria, frequency, urgency, flank pain), treatment becomes necessary:
For Symptomatic Cystitis:
- Fluconazole 200 mg (3 mg/kg) orally daily for 2 weeks is first-line for fluconazole-susceptible Candida species 1, 2, 5
- For fluconazole-resistant organisms (especially C. glabrata): 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, 5
For Pyelonephritis:
- Fluconazole 200-400 mg (3-6 mg/kg) orally daily for 2 weeks for fluconazole-susceptible organisms 1, 2
- For fluconazole-resistant strains: amphotericin B deoxycholate 0.5-0.7 mg/kg daily with or without flucytosine 25 mg/kg four times daily for 2 weeks 1
Critical Pitfalls to Avoid
Do not use echinocandins (caspofungin, micafungin, anidulafungin) for urinary tract Candida infections—these agents achieve minimal urinary concentrations and are ineffective for lower urinary tract infections. 2, 5, 3
Do not use lipid formulations of amphotericin B for isolated urinary tract infections, as they do not achieve adequate urine concentrations. 2, 5, 6
Do not use voriconazole or other azoles besides fluconazole for urinary candidiasis, as they fail to achieve sufficient urine levels. 2, 3
Do not treat asymptomatic candiduria reflexively—this is the most common error and leads to unnecessary antifungal exposure without clinical benefit. 1, 2, 7
Practical Management Approach
For your patient with occasional yeast budding:
- Assess for symptoms: If truly asymptomatic, no treatment is needed 1
- Identify and remove predisposing factors: Remove urinary catheters if present, discontinue unnecessary antibiotics, optimize diabetes control if applicable 1, 2, 8
- Determine risk status: Only treat if patient is neutropenic, a very low-birth-weight infant, or about to undergo urologic manipulation 1, 2
- Repeat urinalysis in 1-2 weeks: Candiduria often resolves spontaneously once predisposing factors are addressed 3, 8