What is the recommended length of a fluconazole (antifungal agent) treatment course for a patient with a urine culture positive for Candida albicans and glabrata?

Treatment Duration for Candida Albicans and Glabrata in Urine

For fluconazole-susceptible Candida albicans and glabrata causing symptomatic urinary tract infection, treat with oral fluconazole 200 mg daily for 2 weeks for cystitis or 200-400 mg daily for 2 weeks for pyelonephritis. 1

Critical First Step: Determine If Treatment Is Indicated

Before initiating antifungal therapy, you must determine whether the patient actually requires treatment, as candiduria often represents colonization rather than infection:

• Do NOT treat asymptomatic candiduria unless the patient is neutropenic, a very low-birth-weight infant (<1500g), or undergoing urologic manipulation 1
• Remove indwelling bladder catheters immediately if feasible, as this alone often resolves candiduria without antifungal therapy 1, 2
• Neutropenic patients and very low-birth-weight infants with candiduria should be treated as candidemia, not simple UTI 1, 2

Treatment Algorithm Based on Susceptibility and Site

For Symptomatic Cystitis (Lower UTI):

• Fluconazole-susceptible organisms (including susceptible C. glabrata): Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks 1, 2
• Fluconazole-resistant 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, 2

For Symptomatic Pyelonephritis (Upper UTI):

• Fluconazole-susceptible organisms: Oral fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks 1, 2
• 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 1

Critical Caveat About C. Glabrata Susceptibility

C. glabrata is frequently fluconazole-resistant or susceptible-dose-dependent, making susceptibility testing essential before choosing fluconazole. 3, 4 The IDSA guidelines explicitly recommend alternative agents for fluconazole-resistant C. glabrata 1, and research shows only 50% efficacy for fluconazole against C. glabrata compared to 93% for C. albicans 3. If you must use fluconazole for susceptible-dose-dependent C. glabrata, higher doses (≥400 mg daily) are more likely to achieve eradication 4.

Special Populations

Hemodialysis Patients:

• Administer fluconazole 200 mg after each hemodialysis session for fluconazole-susceptible organisms 2

Patients Undergoing Urologic Procedures:

• Treat prophylactically with oral fluconazole 400 mg (6 mg/kg) daily OR amphotericin B deoxycholate 0.3-0.6 mg/kg daily for several days before and after the procedure 1

Essential Adjunctive Measures

Removing indwelling catheters significantly improves cure rates and is strongly recommended whenever feasible. 1, 2 Failure to remove catheters is a common pitfall that leads to treatment failure and recurrence 2.

Eliminate urinary tract obstruction (nephrostomy tubes, stents, structural abnormalities) as this is essential for successful treatment 1

Common Pitfalls to Avoid

• Do not use shorter courses than 2 weeks for symptomatic UTI, as this leads to recurrence 2
• Do not assume all Candida species are fluconazole-susceptible—obtain susceptibility testing, especially for C. glabrata 2, 3, 4
• Do not treat asymptomatic candiduria in catheterized patients, as studies show treatment does not improve outcomes and candiduria is merely a marker of underlying illness severity 1
• Do not use fluconazole monotherapy for fluconazole-resistant isolates, even at high doses 1, 2