What is the treatment for a fungal urinary tract infection (UTI) in a patient with yeast in their urine, possibly immunocompromised, diabetic, or using catheters (catheterization)?

Management of Yeast in Urine

For most patients with yeast in their urine who are asymptomatic, no antifungal treatment is needed—simply remove the urinary catheter if present, as this alone clears candiduria in approximately 50% of cases. 1

Initial Assessment: Distinguish Colonization from Infection

The presence of yeast in urine most commonly represents benign colonization rather than true infection, with candiduria progressing to candidemia in less than 5% of cases. 2 Key diagnostic principles include:

• Colony counts and pyuria cannot differentiate colonization from infection, especially in catheterized patients 1, 2
• Candiduria serves as a marker of illness severity rather than a cause of morbidity itself 2
• Treatment does not reduce mortality rates in asymptomatic patients 2

When Treatment is Mandatory (Even if Asymptomatic)

Treat asymptomatic candiduria only in these high-risk populations:

• Neutropenic patients with persistent unexplained fever and candiduria 1, 2
• Very low birth weight neonates at risk for invasive candidiasis 1, 2
• Patients undergoing urologic procedures or instrumentation (high risk for candidemia) 1, 2
• Patients with urinary tract obstruction 1, 2

Do NOT treat asymptomatic candiduria in:

• Otherwise healthy patients 2
• Diabetic patients without other high-risk features 2
• Elderly patients without other indications 2
• Most immunocompromised patients (treatment does not improve outcomes) 2

Treatment Algorithm for Symptomatic Infections

First-Line Non-Pharmacologic Management

Remove the indwelling urinary catheter if feasible—this is a strong recommendation and clears candiduria in ~50% of cases without antifungal therapy. 1, 2

Additional measures include:

• Eliminate urinary tract obstruction (strong recommendation) 1
• Remove or replace nephrostomy tubes/stents if feasible 1
• Discontinue unnecessary broad-spectrum antibiotics 2

Pharmacologic Treatment for Symptomatic Candida Cystitis

For fluconazole-susceptible organisms (most common):

• Fluconazole 200 mg (3 mg/kg) orally daily for 2 weeks (strong recommendation) 1, 2, 3
• Fluconazole is the drug of choice because it achieves high urinary concentrations in its active form and is available orally 1, 4

Treatment for Symptomatic Candida Pyelonephritis

For fluconazole-susceptible organisms:

• Fluconazole 200-400 mg (3-6 mg/kg) orally daily for 2 weeks (strong recommendation) 1, 2

Treatment for Fluconazole-Resistant Species

For fluconazole-resistant C. glabrata:

• Amphotericin B deoxycholate 0.3-0.6 mg/kg IV daily for 1-7 days (strong recommendation) 1, 2
• Alternative: Oral flucytosine 25 mg/kg four times daily for 7-10 days (strong recommendation) 1, 2
• Combination therapy with both agents can be considered 1

For C. krusei:

• Amphotericin B deoxycholate 0.3-0.6 mg/kg IV daily for 1-7 days (strong recommendation) 1

Prophylaxis for Urologic Procedures

For patients undergoing urologic procedures with candiduria:

• Fluconazole 200-400 mg (3-6 mg/kg) daily for several days before and after the procedure 2

Special Considerations for High-Risk Populations

Catheter-Associated Candiduria

• Catheterization duration is the most important risk factor for development 1
• Diabetes, female sex, prolonged catheterization, and longer hospital stays increase risk 1
• Catheter removal is strongly recommended as first-line management 1

Diabetic and Immunocompromised Patients

• Diabetes and immunosuppression are risk factors for complicated UTI 1
• However, diabetes or advanced age alone does NOT mandate treatment in asymptomatic patients 2
• Appropriate management of underlying urological abnormalities is mandatory 1

Critical Pitfalls to Avoid

• Do not reflexively treat asymptomatic candiduria—most cases represent benign colonization 2
• Do not rely on colony counts or pyuria to differentiate infection from colonization 2
• Do not use echinocandins or newer azoles (except fluconazole) for urinary tract infections—they fail to achieve adequate urine concentrations 5, 6
• Do not overlook disseminated candidiasis in high-risk patients with candiduria 2
• Do not assume diabetes alone mandates treatment in asymptomatic patients 2

Agents to Avoid for Candida UTI

Echinocandins and azoles other than fluconazole do not achieve measurable urinary concentrations and should not be used for Candida UTI. 5, 6 Amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) may be useful only for fluconazole-resistant cystitis, but has limited utility overall. 1