What is the recommended treatment for candiduria in an adult without known fluconazole‑resistant Candida, including first‑line fluconazole dosing, catheter removal, and alternative therapies for resistant or intolerant cases?

Treatment for Fungal Urine Infection (Candiduria)

For symptomatic Candida cystitis in adults without fluconazole-resistant species, fluconazole 200 mg (3 mg/kg) orally once daily for 14 days is the first-line treatment, and removing any indwelling urinary catheter is mandatory as it clears candiduria in approximately 50% of cases without antifungal therapy. 1, 2

Initial Assessment: Distinguish Colonization from Infection

• Asymptomatic candiduria does NOT require treatment in most patients, as it represents colonization rather than infection and treatment does not improve mortality or outcomes. 2
• Candiduria progresses to candidemia in less than 5% of cases and serves as a marker of illness severity rather than a cause of morbidity itself. 2
• Symptomatic infection (dysuria, frequency, urgency, flank pain, fever) requires treatment in all patients. 2
• Do not rely on colony counts or pyuria to differentiate colonization from infection—these are unreliable indicators, especially in catheterized patients. 2

High-Risk Asymptomatic Patients Who Require Treatment

Despite being asymptomatic, the following groups require aggressive treatment: 1, 2

• Neutropenic patients with persistent unexplained fever and candiduria
• Very low birth weight neonates (<1500 g)
• Patients undergoing urologic procedures or instrumentation (treat with fluconazole 200-400 mg daily for several days before and after the procedure) 1, 2

First-Line Treatment for Symptomatic Cystitis

For fluconazole-susceptible Candida species:

• Fluconazole 200 mg (3 mg/kg) orally once daily for 14 days is the preferred regimen based on randomized controlled trial evidence. 1, 2
• Fluconazole is favored because it achieves high urinary concentrations of active drug, ensuring effective pathogen eradication. 1, 2, 3

Treatment for Symptomatic Pyelonephritis

For fluconazole-susceptible organisms:

• Fluconazole 200-400 mg (3-6 mg/kg) orally once daily for 14 days is recommended. 1, 2
• Use the higher dose of 400 mg daily when upper tract involvement is confirmed. 2

Management of Fluconazole-Resistant Species

Candida glabrata (often fluconazole-resistant):

• Amphotericin B deoxycholate 0.3-0.6 mg/kg IV daily for 1-7 days with or without oral flucytosine 25 mg/kg four times daily for 7-10 days. 1, 2
• Oral flucytosine 25 mg/kg four times daily for 7-10 days as monotherapy may be considered when amphotericin B is unsuitable (weaker recommendation). 1, 2

Candida krusei (intrinsically fluconazole-resistant):

• Amphotericin B deoxycholate 0.3-0.6 mg/kg IV daily for 1-7 days is the treatment of choice. 1, 2

Bladder Irrigation for Resistant Cystitis:

• Amphotericin B deoxycholate bladder irrigation (50 mg/L sterile water daily for 5 days) can be employed for refractory cystitis caused by fluconazole-resistant species such as C. glabrata or C. krusei. 1, 2
• This approach is generally discouraged except for refractory cases, as relapse rates are high. 1
• Bladder irrigation may be preferred in patients with renal dysfunction, where it has shown superior cure rates compared to systemic fluconazole. 4

Essential Non-Pharmacologic Management

• Remove any indwelling bladder catheter immediately—this is the single most important intervention and resolves candiduria in approximately 50% of cases without antifungal therapy. 1, 2, 3
• Continuing catheters is the most common cause of treatment failure. 2
• Eliminate urinary tract obstruction to facilitate infection clearance. 1, 2
• Remove or replace nephrostomy tubes or ureteral stents if present to reduce fungal burden. 1, 2

Management of Fungal Balls and Complicated Infections

• Surgical intervention is strongly recommended for urinary fungus balls in addition to antifungal therapy. 1, 2
• Irrigation through nephrostomy tubes with amphotericin B deoxycholate 25-50 mg in 200-500 mL sterile water is recommended as an adjunct to systemic therapy. 1

Critical Pitfalls to Avoid

• Do not treat asymptomatic candiduria reflexively—most cases represent benign colonization and treatment does not reduce mortality. 2
• Do not assume diabetes or advanced age alone mandates treatment—these are risk factors for candiduria but not indications for treatment in asymptomatic patients. 2
• Do not use echinocandins or newer azoles (voriconazole, posaconazole) for urinary tract infections, as they fail to achieve adequate urine concentrations. 3
• Do not overlook the possibility of disseminated candidiasis in high-risk patients (neutropenic, very low birth weight neonates) with candiduria—these patients should be treated as for candidemia. 1, 2