Treatment Decision for Candida Glabrata Candiduria (50,000-99,000 CFU/mL)
Do not treat with IV antifungal therapy unless this patient is neutropenic, a very low-birth-weight infant (<1500g), or about to undergo urologic instrumentation—otherwise, simply remove the urinary catheter if present and observe. 1
Risk Stratification: Who Requires Treatment?
The IDSA guidelines explicitly state that antifungal therapy is NOT recommended for candiduria unless the patient belongs to a high-risk group for dissemination 1:
- Neutropenic patients (treat as candidemia with systemic therapy) 1
- Very low-birth-weight infants (<1500g) (treat as candidemia) 1
- Patients undergoing urologic procedures (prophylactic treatment for several days before and after) 1
For all other patients—including those with diabetes, indwelling catheters, or ICU admission—asymptomatic candiduria does not warrant treatment regardless of colony count 1, 2, 3.
First-Line Management: Catheter Removal
Remove the indwelling bladder catheter immediately if feasible—this alone resolves candiduria in approximately 40-50% of cases without any antifungal therapy 4, 5. This is a strong recommendation and should be your primary intervention 1.
When Symptoms Are Present: Oral Therapy First
If the patient has symptomatic cystitis (dysuria, frequency, urgency, suprapubic pain) with documented C. glabrata:
- For fluconazole-susceptible C. glabrata: Oral fluconazole 200 mg daily for 2 weeks 1
- For fluconazole-resistant C. glabrata: Amphotericin B deoxycholate 0.3-0.6 mg/kg IV daily for 1-7 days OR oral flucytosine 25 mg/kg four times daily for 7-10 days 1
Note that C. glabrata is frequently fluconazole-resistant or susceptible-dose-dependent, so susceptibility testing is critical 1.
Why IV Therapy Is Usually Wrong
IV echinocandins and most azoles (except fluconazole) do not achieve adequate urinary concentrations and are ineffective for Candida UTI 4, 5, 2. While isolated case reports describe success with micafungin for C. glabrata pyelonephritis and fungemia 6, 7, these involved systemic infection with bacteremia, not isolated candiduria. The IDSA guidelines do not support echinocandins for lower urinary tract infections 4.
Caspofungin specifically failed in a case of obstructive C. glabrata pyonephrosis and required drainage plus amphotericin B instillation 8. This underscores that obstruction must be relieved and that echinocandins have limited utility in the urinary tract 8.
Critical Pitfall: Treating Colonization
The colony count of 50,000-99,000 CFU/mL is irrelevant to the treatment decision—candiduria almost always represents colonization in asymptomatic patients, not true infection 4, 2, 3. The presence of symptoms, neutropenia, or planned urologic procedures determines treatment need, not the quantitative culture result 1.
Special Consideration: Urinary Obstruction
If urinary retention or obstruction is present, elimination of obstruction is mandatory alongside antifungal therapy 1, 4. For nephrostomy tubes or stents, consider removal or replacement if feasible 1. Obstruction precludes successful antifungal treatment alone 4, 8.
Assessment for Disseminated Disease
In neutropenic or severely immunocompromised patients with candiduria, assess for disseminated candidiasis, as candiduria may represent hematogenous seeding rather than ascending infection 1, 4, 3. These patients require systemic antifungal therapy as for candidemia 1.