What is the treatment for Candida albicans in the urine of a male patient?

Management of Candida albicans in Urine in Men

Most asymptomatic men with Candida albicans in urine require only observation and removal of predisposing factors—antifungal therapy is not indicated unless specific high-risk conditions or symptoms are present. 1

Initial Assessment: Distinguish Colonization from Infection

The critical first step is determining whether candiduria represents asymptomatic colonization (most common) or true infection requiring treatment:

• Asymptomatic candiduria in otherwise healthy men represents colonization in the vast majority of cases and should not be treated. 1, 2
• Remove any indwelling urinary catheter if present—this alone clears candiduria in approximately 50% of asymptomatic patients without any antifungal therapy. 1, 3
• Eliminate other predisposing factors such as unnecessary broad-spectrum antibiotics, optimize diabetes control if present, and address any urinary obstruction. 1, 2

Mandatory Treatment Scenarios for Asymptomatic Candiduria

Even without symptoms, treatment is required in these specific high-risk situations:

• Neutropenic patients 1
• Patients with planned urologic procedures 1
• Severely immunocompromised patients with fever 1
• Patients with urinary tract obstruction or retention 1, 3

Treatment Algorithm for Symptomatic Infections

Symptomatic Cystitis (dysuria, frequency, urgency, suprapubic discomfort)

• First-line: Fluconazole 200 mg (3 mg/kg) orally daily for 2 weeks 1, 4, 5
• Fluconazole achieves high urinary concentrations in active form, making it superior to all other antifungals for lower urinary tract infections. 1, 2
• C. albicans is typically fluconazole-susceptible, making this the optimal choice. 4

Pyelonephritis (flank pain, fever, systemic signs)

• Fluconazole 200-400 mg (3-6 mg/kg) orally daily for 2 weeks for fluconazole-susceptible organisms 1, 5
• For fluconazole-resistant C. glabrata: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days with or without flucytosine 25 mg/kg four times daily 1, 4, 5

Prostatitis/Epididymo-orchitis

• Fluconazole is the agent of choice, with dosing extrapolated from cystitis recommendations (200 mg daily for 2 weeks). 1

Pre-Procedure Prophylaxis

• For men undergoing urologic procedures with documented candiduria: 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

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, 4
• Do not use other azoles besides fluconazole (voriconazole, posaconazole)—they have poor urinary excretion. 1, 4
• Do not use lipid formulations of amphotericin B—they do not achieve adequate urine concentrations. 1, 4
• Do not treat asymptomatic candiduria in otherwise healthy men—treatment does not prevent complications and represents unnecessary therapy. 1, 2
• Do not overlook the possibility of disseminated candidiasis in high-risk patients (neutropenic, severely immunocompromised) with candiduria—assess for additional risk factors. 3

Special Considerations

Fungus Balls

• Surgical or endoscopic removal is mandatory for fungus balls obstructing the urinary tract. 1
• Adjunctive systemic fluconazole or amphotericin B deoxycholate therapy should accompany mechanical removal. 1, 6

Treatment Duration and Monitoring

• Standard duration: 2 weeks for both cystitis and pyelonephritis 1, 4, 5
• Continue therapy until symptoms resolve and urine cultures are negative for Candida species. 1, 4
• Obtain repeat urine culture to confirm eradication after treatment completion. 5

Species-Specific Considerations

• C. albicans (most common, 60% of isolates) is typically fluconazole-susceptible. 4, 5
• C. glabrata often requires alternative therapy due to fluconazole resistance—use amphotericin B deoxycholate or flucytosine. 1, 4