When should yeast in urinalysis be treated in patients with or without symptoms, considering underlying health status and risk factors for complications?

When to Treat Yeast in Urinalysis

Do not treat asymptomatic candiduria in most patients, as it represents benign colonization rather than infection and treatment does not improve mortality or outcomes. 1

Asymptomatic Candiduria: Observation Only

The vast majority of patients with yeast in urine require no antifungal therapy. The key principle is that candiduria almost always represents colonization, not infection, and treatment provides no benefit while promoting resistance. 1

Critical evidence:

• Candiduria progresses to candidemia in less than 5% of cases 1, 2
• Treatment does not reduce mortality rates 1
• Candiduria resolves spontaneously in 76% of untreated cases 3
• Removing an indwelling urinary catheter alone clears candiduria in approximately 50% of cases without antifungal therapy 1, 4

Do NOT treat asymptomatic candiduria in:

• Otherwise healthy patients 1
• Diabetic patients without other high-risk features 1
• Elderly or institutionalized patients 1
• Immunocompromised patients (including most transplant recipients) 1

Mandatory Treatment Scenarios (Even if Asymptomatic)

Treat asymptomatic candiduria only in these specific high-risk situations:

1. Neutropenic patients with persistent unexplained fever and candiduria 1, 4

• This population requires aggressive treatment as candiduria may indicate disseminated candidiasis 4

2. Very low birth weight neonates 1, 4

• At high risk for invasive candidiasis involving the urinary tract 1

3. Patients undergoing urologic procedures or instrumentation 1, 4

• High risk for candidemia during mucosal breach 1
• Pre-procedure prophylaxis: Fluconazole 400 mg (6 mg/kg) daily for several days before and after the procedure 4

4. Patients with urinary tract obstruction 1, 4

• Obstruction prevents clearance and increases risk of ascending infection 1

Symptomatic Candiduria: Always Treat

Treat all patients with urinary symptoms attributable to Candida:

Symptomatic Cystitis (dysuria, frequency, urgency)

• First-line: Fluconazole 200 mg (3 mg/kg) orally daily for 2 weeks 1, 4
• Fluconazole achieves high urinary concentrations in active form, making it superior to all other antifungals 4

Symptomatic Pyelonephritis (fever, flank pain)

• First-line: Fluconazole 200-400 mg (3-6 mg/kg) orally daily for 2 weeks for susceptible organisms 1, 4

Fluconazole-Resistant Species (C. glabrata, C. krusei)

• Alternative: Amphotericin B deoxycholate 0.3-0.6 mg/kg IV daily for 1-7 days 1, 3
• With or without: Oral flucytosine 25 mg/kg four times daily for 7-10 days 1, 3

First-Line Management: Remove Predisposing Factors

Before considering antifungals, address modifiable risk factors:

• Remove indwelling urinary catheters (clears candiduria in ~50% of cases) 1, 4
• Discontinue unnecessary broad-spectrum antibiotics 1
• Optimize diabetes control 2
• Address urinary tract obstruction 1

Critical Pitfalls to Avoid

Do NOT use these agents for Candida UTI:

• Echinocandins (caspofungin, micafungin, anidulafungin): Achieve poor urinary concentrations and are ineffective for lower UTI 4, 3
• Lipid formulations of amphotericin B: Do not achieve adequate urine concentrations 4, 3
• Other azoles (voriconazole, posaconazole): Fail to achieve therapeutic urine levels 4, 5

Only three agents achieve adequate urinary concentrations:

• Fluconazole (preferred) 4
• Amphotericin B deoxycholate 4
• Flucytosine 4

Do NOT reflexively treat asymptomatic candiduria:

• Most cases represent benign colonization 1
• Treatment does not prevent complications in low-risk patients 1, 3
• Unnecessary treatment promotes antifungal resistance 3

Special Considerations

Fungus Balls

• Require surgical or endoscopic removal 4
• Use adjunctive systemic fluconazole or amphotericin B deoxycholate 4

Candida Prostatitis/Epididymo-orchitis

• Fluconazole is the agent of choice 4
• Dose and duration extrapolated from cystitis recommendations 4

Post-Treatment Monitoring

• Continue therapy until symptoms resolve and urine cultures are negative 4
• Standard duration: 2 weeks for cystitis and pyelonephritis 4
• Colony counts and pyuria should not be used to differentiate colonization from infection 1