What is the recommended treatment for a symptomatic Candida urinary tract infection?

Treatment of Symptomatic Candida Urinary Tract Infection

For symptomatic Candida cystitis, treat with fluconazole 200 mg (3 mg/kg) orally once daily for 14 days. 1, 2

Treatment Algorithm by Site of Infection

Symptomatic Cystitis (Lower UTI)

• Fluconazole 200 mg (3 mg/kg) orally daily for 2 weeks is the first-line treatment for fluconazole-susceptible Candida species 1, 2
• This recommendation is based on the only randomized, double-blind, placebo-controlled trial demonstrating efficacy 2
• Fluconazole achieves excellent urinary concentrations of active drug, making it ideal for lower urinary tract infections 2, 3

Symptomatic Pyelonephritis (Upper UTI)

• Fluconazole 200-400 mg (3-6 mg/kg) orally daily for 2 weeks for fluconazole-susceptible organisms 1, 2
• Use the higher 400 mg daily dose when upper tract involvement is confirmed 2
• If disseminated candidiasis is suspected alongside pyelonephritis, treat as candidemia rather than isolated UTI 1

Essential Non-Pharmacologic Management

Remove indwelling urinary catheters immediately—this single intervention clears candiduria in approximately 50% of cases without any antifungal therapy. 2, 3

Additional non-pharmacologic measures include:

• Eliminate urinary tract obstruction if present 2, 3
• Remove or replace nephrostomy tubes or ureteral stents 2
• Discontinue unnecessary broad-spectrum antibiotics 2

Treatment of Fluconazole-Resistant Species

For Candida glabrata (often fluconazole-resistant):

• Amphotericin B deoxycholate 0.3-0.6 mg/kg IV daily for 1-7 days 1, 2
• Alternative: Oral flucytosine 25 mg/kg four times daily for 7-10 days 1, 2
• Amphotericin B with or without flucytosine can be used in combination 1

For Candida krusei (intrinsically fluconazole-resistant):

• Amphotericin B deoxycholate 0.3-0.6 mg/kg IV daily for 1-7 days 2
• For refractory cases, amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) may be added 1, 2

Special Populations Requiring Treatment Despite Being Asymptomatic

Treatment is mandatory for asymptomatic candiduria in these high-risk groups:

• 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: give fluconazole 200-400 mg (3-6 mg/kg) daily for several days before and after the procedure 1, 2, 3

Critical Pitfalls to Avoid

Do not use echinocandins (caspofungin, micafungin, anidulafungin) for Candida UTI—they achieve minimal urinary concentrations and are ineffective for lower urinary tract infections. 3

Additional pitfalls:

• Do not use lipid formulations of amphotericin B for UTI, as they fail to achieve adequate urine concentrations 3
• Do not treat asymptomatic candiduria in otherwise healthy patients, diabetics without other risk factors, or elderly patients without additional indications—treatment does not reduce mortality and promotes resistance 2, 3
• Do not rely on colony counts or pyuria to distinguish colonization from infection in catheterized patients, as these are unreliable 2
• Do not use voriconazole, posaconazole, or itraconazole for UTI, as other azoles besides fluconazole do not achieve sufficient urinary levels 3, 4

When to Suspect Disseminated Disease

Evaluate for complications including:

• Urinary fungus balls (require surgical removal plus systemic antifungals) 1
• Candidemia (less than 5% of candiduria cases progress to bloodstream infection) 2
• Disseminated candidiasis in high-risk patients with pyelonephritis 1