What are the indications for treatment of candiduria in patients with underlying medical conditions, such as neutropenia, recent organ transplant, or those receiving broad-spectrum antibiotics?

Indications for Treatment of Candiduria

Asymptomatic candiduria should NOT be treated in most patients, as it represents benign colonization rather than infection and treatment does not improve mortality or outcomes. 1

High-Risk Populations Requiring Treatment Despite Absence of Symptoms

Treatment is indicated for asymptomatic candiduria only in these specific high-risk groups:

• Neutropenic patients with persistent unexplained fever and candiduria require aggressive treatment, as this may indicate invasive candidiasis 2, 1, 3
• Very low birth weight neonates are at risk for invasive candidiasis involving the urinary tract and require treatment 2, 1, 3
• Patients undergoing urologic procedures or instrumentation (cystoscopy, ureteroscopy, transurethral resection) require treatment due to documented high rates of candidemia following manipulation 2, 1, 3
  • For these patients, administer fluconazole 200-400 mg (3-6 mg/kg) daily for several days before and after the procedure 2
• Patients with urinary tract obstruction where candiduria may lead to ascending infection 3, 4

Symptomatic Infections Always Requiring Treatment

Candida Cystitis

• Fluconazole 200 mg (3 mg/kg) daily for 2 weeks is the treatment of choice for fluconazole-susceptible species 2, 1, 3
• For fluconazole-resistant organisms (C. glabrata, C. krusei):
  • Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 2, 3
  • OR oral flucytosine 25 mg/kg four times daily for 7-10 days 2, 3

Candida Pyelonephritis

• Fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks for fluconazole-susceptible organisms 2, 1, 3
• For fluconazole-resistant strains (especially C. glabrata):
  • Amphotericin B deoxycholate 0.5-0.7 mg/kg daily with or without flucytosine 25 mg/kg four times daily for 2 weeks 2
  • OR flucytosine alone 25 mg/kg four times daily for 2 weeks 2

Suspected Disseminated Candidiasis

• Treat as candidemia with systemic antifungal therapy 2

First-Line Non-Pharmacologic Management

Remove indwelling urinary catheters immediately when present, as this alone clears candiduria in approximately 40-50% of cases without antifungal therapy 1, 3, 4

Additional non-pharmacologic measures:

• Discontinue unnecessary broad-spectrum antibiotics 1
• Address underlying urinary tract abnormalities 1

Critical Clinical Context

Candiduria rarely progresses to candidemia, occurring in less than 5% of cases, even in high-risk populations 1, 3. The presence of candiduria serves as a marker of illness severity rather than a cause of morbidity itself 1. Treatment of asymptomatic candiduria does not reduce mortality rates 1.

Important Pitfalls to Avoid

• Do not treat asymptomatic candiduria reflexively in immunocompetent patients, as most cases represent benign colonization 1
• Do not assume diabetes or advanced age alone mandates treatment, as these are risk factors for candiduria but not indications for treatment in asymptomatic patients 1
• Do not use echinocandins for lower urinary tract Candida infections, as they achieve poor urinary concentrations despite being well-tolerated systemically 4, 5, 6
• Do not overlook the possibility of disseminated candidiasis in high-risk patients (neutropenic, transplant recipients) with candiduria 1, 4
• Do not use azoles other than fluconazole (voriconazole, posaconazole, itraconazole) for urinary tract infections, as they do not achieve adequate urinary concentrations 4, 6

Special Considerations for Transplant Recipients

In solid organ transplant recipients with symptomatic candiduria caused by fluconazole-resistant species (C. krusei), higher-dose echinocandins may be considered when other options are contraindicated due to nephrotoxicity or drug interactions, though this is off-guideline 7. However, fluconazole remains the preferred agent when susceptibility allows 5.