What is the appropriate treatment for a male patient with a complicated urinary tract infection and ≥2+ yeast on urinalysis?

Treatment for Male Complicated UTI with 2+ Yeast on Urinalysis

For a male patient with complicated UTI and ≥2+ yeast on urinalysis, first determine if the patient is symptomatic; if asymptomatic, treatment is not recommended unless the patient is neutropenic, an infant with low birth weight, or undergoing urologic procedures, but if symptomatic with cystitis, treat with oral fluconazole 200 mg daily for 2 weeks. 1

Initial Clinical Assessment

The presence of yeast in urine must be evaluated in the clinical context to determine if it represents contamination, colonization, or true infection 1. Key steps include:

• Assess for symptoms: Look for acute dysuria, fever, suprapubic pain, frequency, urgency, or signs of systemic infection 1
• Evaluate for upper tract involvement: Check for costovertebral angle tenderness, flank pain, or fever suggesting pyelonephritis 1
• Identify predisposing factors: Diabetes mellitus, indwelling catheters, recent antibiotic use, urinary obstruction, or immunosuppression increase risk of true candidal infection 1, 2
• Obtain urine culture: This is mandatory before initiating therapy to confirm Candida species and guide treatment adjustments 1, 3

Treatment Algorithm Based on Clinical Presentation

Asymptomatic Candiduria (Most Common Scenario)

• Do not treat unless the patient belongs to a high-risk group 1
• Remove predisposing factors: Discontinue unnecessary antibiotics, remove indwelling catheters if possible—this alone resolves candiduria in approximately 50% of cases 1, 4
• High-risk patients requiring treatment include neutropenic patients, low birth weight infants, and those undergoing urologic procedures 1
• For patients undergoing urologic procedures, give fluconazole 200-400 mg daily or amphotericin B deoxycholate 0.3-0.6 mg/kg daily for several days before and after the procedure 1

Symptomatic Candidal Cystitis

This is the most likely scenario requiring treatment in your case:

• First-line therapy: Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks for fluconazole-susceptible Candida species 1
• Alternative for fluconazole-resistant organisms: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days OR oral flucytosine 25 mg/kg four times daily for 7-10 days 1, 2
• For C. glabrata (often fluconazole-resistant): Consider amphotericin B bladder irrigation in addition to systemic therapy, though this is generally not recommended as monotherapy 1

Candidal Pyelonephritis

• For fluconazole-susceptible organisms: Oral fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks 1
• For fluconazole-resistant strains (especially C. glabrata): Amphotericin B deoxycholate 0.5-0.7 mg/kg daily with or without flucytosine 25 mg/kg four times daily, OR flucytosine alone 25 mg/kg four times daily for 2 weeks 1

Suspected Disseminated Candidiasis

• Treat as candidemia with systemic antifungal therapy per invasive candidiasis guidelines 1
• This requires hospitalization and parenteral therapy with echinocandins or lipid formulations of amphotericin B 1

Critical Management Considerations

Why Fluconazole is Preferred

• Achieves high urinary concentrations with oral formulation, making it ideal for urinary tract infections 4, 2
• Oral bioavailability allows outpatient management in stable patients 4
• Newer azoles and echinocandins are NOT recommended for urinary tract infections because they fail to achieve adequate urine concentrations 4

Common Pitfalls to Avoid

• Do not treat asymptomatic candiduria in non-high-risk patients—this increases antimicrobial resistance without clinical benefit 1, 4
• Do not use echinocandins (caspofungin, micafungin, anidulafungin) for isolated urinary candidiasis—they do not achieve therapeutic urine levels 4
• Do not assume all yeast is C. albicans—obtain culture and susceptibility testing, as C. glabrata and other non-albicans species may be fluconazole-resistant 1, 2
• Do not forget to address the bacterial component—this is a complicated UTI in a male, so concurrent bacterial infection is likely and requires appropriate antibacterial therapy for 14 days 3

Concurrent Bacterial UTI Management

Since this is a complicated UTI in a male with yeast, you must also address potential bacterial pathogens:

• Obtain urine culture before starting antibiotics to guide therapy 3
• First-line antibacterial therapy: Trimethoprim-sulfamethoxazole for 14 days (if local resistance <20%) 3
• Alternative options: Ciprofloxacin 500 mg twice daily for 14 days (if local resistance <10% and not used in past 6 months) OR cefpodoxime 200 mg twice daily for 10-14 days 3
• Treatment duration: 14 days is standard for male UTIs when prostatitis cannot be excluded, which applies to most presentations 3

Follow-Up and Monitoring

• Reassess at 48-72 hours: If symptoms persist or worsen, obtain repeat culture and consider imaging 3
• Post-treatment urine culture: Consider repeat culture after completing therapy to document clearance, especially in high-risk patients 1
• Evaluate for underlying abnormalities: Recurrent or persistent candiduria warrants evaluation for urologic abnormalities, diabetes, or immunosuppression 1, 2