What is the recommended treatment for a patient with candidal cystitis?

Treatment of Candidal Cystitis

For symptomatic candidal cystitis, fluconazole 200 mg (3 mg/kg) daily for 14 days is the recommended first-line treatment. 1

Initial Assessment and Risk Stratification

Before initiating treatment, determine whether candiduria represents true infection versus asymptomatic colonization 2:

• Symptomatic cystitis requires treatment with dysuria, frequency, urgency, or suprapubic pain 1
• Asymptomatic candiduria does NOT require treatment in most patients 1, 3
• High-risk exceptions requiring treatment even if asymptomatic: neutropenic patients, very low-birth-weight infants, and patients undergoing urologic procedures 2, 3

Critical First Steps Before Antifungal Therapy

Remove or replace indwelling urinary catheters immediately - this alone resolves candiduria in approximately 50% of cases 2, 4, 5:

• Catheter removal is the single most important intervention 4, 5
• Eliminate any urinary tract obstruction present 3
• Remove or replace nephrostomy tubes or stents if feasible 3

Antifungal Treatment Algorithm

For Fluconazole-Susceptible Species (C. albicans, most C. tropicalis, C. parapsilosis)

Fluconazole 200 mg (3 mg/kg) orally daily for 14 days 1:

• Achieves excellent urinary concentrations with oral formulation 3, 6, 5
• Strong safety profile, particularly for immunocompromised patients 3
• Most C. albicans (60% of isolates) are susceptible 4

For Fluconazole-Resistant Species (C. krusei, fluconazole-resistant C. glabrata)

Amphotericin B deoxycholate 0.3-0.6 mg/kg IV daily for 1-7 days 1, 2:

• Alternative for resistant species, allergy, or treatment failure 6
• Can add flucytosine 25 mg/kg orally 4 times daily for resistant strains 1
• Alternative: Amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) for isolated cystitis 2

Important Caveats and Pitfalls

Avoid echinocandins and newer azoles (voriconazole, posaconazole) for urinary tract infections - they fail to achieve adequate urine concentrations 1, 5:

• Echinocandins should be limited to salvage therapy only 1
• These agents are appropriate for candidemia but not isolated cystitis 5

Do not treat asymptomatic candiduria routinely - this represents colonization in most hospitalized patients and treatment does not prevent complications 3, 6:

• Exception: treat before urologic procedures with fluconazole 400 mg (6 mg/kg) daily for several days before and after 3

Special Situations

Fungus Balls

Surgical intervention (transurethral removal) combined with systemic fluconazole 3, 7:

• Consider bladder irrigation with saline or antifungal agents before surgery to decrease size 7
• Reduces risk of fungemia during manipulation 7

Suspected Pyelonephritis or Disseminated Disease

Treat as candidemia rather than isolated cystitis 1, 3:

• Fluconazole 200-400 mg (3-6 mg/kg) daily for 14 days for susceptible species 3
• Amphotericin B 0.5-0.7 mg/kg daily with or without flucytosine for resistant strains 4
• Neutropenic patients always require treatment as disseminated candidiasis 3

Monitoring

Obtain repeat urine cultures to document clearance 2:

• Verify negative cultures after completing 14-day treatment course 2
• Ensure resolution of symptoms 3