Do we treat yeast in the urine?

Treatment of Yeast in Urine

Most patients with yeast in the urine (candiduria) do NOT require antifungal treatment, as this typically represents asymptomatic colonization rather than true infection. 1, 2

When to Observe (No Treatment Needed)

• Asymptomatic candiduria in otherwise healthy patients requires only observation and removal of predisposing factors—not antifungal therapy. 1, 2, 3
• Removing an indwelling urinary catheter alone clears candiduria in approximately 50% of asymptomatic patients without any antifungal treatment. 2, 4
• Candidemia occurs in fewer than 5% of patients with asymptomatic candiduria, making empiric treatment unnecessary in most cases. 2

Mandatory Treatment Scenarios

Treatment is required only in specific high-risk situations: 1, 2

• Neutropenic patients with candiduria and persistent unexplained fever 1, 2
• Very low-birth-weight infants with candiduria 2
• Patients undergoing urologic procedures or manipulations 1, 2
• Severely immunocompromised patients with fever and candiduria 2
• Patients with urinary tract obstruction 2
• Symptomatic patients with cystitis (dysuria, frequency, urgency) or pyelonephritis (fever, flank pain) 1, 5

Treatment Algorithm for Symptomatic Infections

For Symptomatic Cystitis (Lower UTI)

• Fluconazole 200 mg (3 mg/kg) orally daily for 2 weeks is the first-line treatment for fluconazole-susceptible Candida species. 1, 5, 3
• Fluconazole is superior to all other antifungals because it achieves high urinary concentrations in its active form. 1, 3

For Fluconazole-Resistant Species

• For C. glabrata (fluconazole-resistant): 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, 5
• For C. krusei: Amphotericin B deoxycholate 0.3–0.6 mg/kg daily for 1–7 days. 1
• Oral flucytosine monotherapy 25 mg/kg four times daily for 2 weeks can be considered for fluconazole-resistant C. glabrata as an alternative. 1

For Pyelonephritis (Upper UTI)

• Fluconazole 200–400 mg (3–6 mg/kg) daily for 2 weeks for fluconazole-susceptible organisms. 1, 3
• For fluconazole-resistant organisms, use the same regimens as listed above for resistant cystitis. 1

Pre-Procedure Prophylaxis

• For patients undergoing urologic procedures with candiduria: Fluconazole 400 mg (6 mg/kg) daily for several days before and after the procedure. 2, 3
• Alternative: Amphotericin B deoxycholate 0.3–0.6 mg/kg daily for several days before and after the procedure. 3

Critical Pitfalls to Avoid

• Do NOT use echinocandins (caspofungin, micafungin, anidulafungin) for Candida UTI—they achieve minimal urinary concentrations and are ineffective for lower tract infections. 1, 3, 4
• Do NOT use lipid formulations of amphotericin B—they do not achieve adequate urine concentrations for treating UTI. 1, 5
• Do NOT use other azoles besides fluconazole (voriconazole, posaconazole, isavuconazole)—they have poor urinary excretion. 1, 2
• Do NOT treat asymptomatic candiduria in otherwise healthy patients—treatment does not prevent complications and candiduria often recurs. 2, 3, 6

Additional Management Considerations

• Always eliminate urinary tract obstruction if present—this is essential for treatment success. 1
• Remove or replace nephrostomy tubes or stents if feasible in patients with persistent candiduria. 1
• Obtain imaging (ultrasound or CT) to rule out structural abnormalities, hydronephrosis, abscesses, or fungus ball formation in symptomatic patients. 1, 5
• For fungus balls: Aggressive surgical debridement is mandatory, with adjunctive systemic fluconazole or amphotericin B therapy. 1, 3

Species-Specific Considerations

• C. albicans (most common, ~60% of isolates) is typically fluconazole-susceptible and easy to treat. 5, 7
• C. glabrata (accounts for ~20% of adult urine isolates) is frequently fluconazole-resistant and requires alternative therapy. 1, 5
• C. krusei is intrinsically fluconazole-resistant and requires amphotericin B. 1