How should I treat a 55-year-old male with dysuria, urinary frequency, no fever, and urinalysis showing pyuria and candiduria?

Treatment of Candiduria with Pyuria in a 55-Year-Old Male

Remove the urinary catheter immediately if present, as this single intervention clears candiduria in approximately 50% of cases without antifungal therapy, and start fluconazole 200 mg orally once daily for 14 days because the patient has symptomatic Candida cystitis (dysuria and frequency) with documented pyuria. 1, 2

Diagnostic Confirmation

• The combination of urinary symptoms (dysuria, frequency), pyuria, and yeast on urinalysis indicates symptomatic Candida cystitis requiring treatment rather than asymptomatic colonization. 1, 2

• Candiduria with symptoms such as dysuria, frequency, urgency, flank pain, or fever mandates antifungal therapy in all patients. 2

• The absence of fever and tachycardia does not exclude the need for treatment when local urinary symptoms and pyuria are present. 1, 2

First-Line Treatment Regimen

• Fluconazole 200 mg (3 mg/kg) orally once daily for 14 days is the preferred first-line agent for symptomatic Candida cystitis caused by fluconazole-susceptible species. 1, 2, 3

• Fluconazole achieves high urinary concentrations of active drug, ensuring effective eradication even with oral administration. 2, 3

• This recommendation is based on the only randomized, double-blind, placebo-controlled trial demonstrating efficacy in this population. 2

Essential Non-Pharmacologic Management

• Immediate removal of any indwelling urinary catheter is the single most important intervention, resolving candiduria in roughly 50% of cases without antifungal drugs. 1, 2, 3

• Continuing an indwelling catheter is the most common cause of treatment failure in candiduria management. 2

• Eliminate unnecessary antibiotics if the patient is currently receiving them, as broad-spectrum antibiotics are a major risk factor for candiduria. 1, 2

Treatment for Fluconazole-Resistant Species

• If Candida glabrata or Candida krusei is identified on culture, fluconazole will be ineffective and alternative therapy is required. 1, 2

• For fluconazole-resistant C. glabrata: use 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. 1, 2

• For C. 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

When to Suspect Upper Tract Involvement

• If the patient develops flank pain, fever >38.3°C, or systemic signs, suspect Candida pyelonephritis and increase fluconazole to 200–400 mg (3–6 mg/kg) daily for 14 days. 1, 2

• Obtain renal/bladder ultrasound or CT imaging if symptoms persist beyond 48–72 hours to exclude obstruction, fungal balls, or perinephric abscess. 1, 2

• Fungal balls or casts in the renal pelvis or bladder require surgical intervention in addition to systemic antifungal therapy. 1, 2

Critical Pitfalls to Avoid

• Do not use echinocandins (caspofungin, micafungin, anidulafungin) for urinary Candida infections, as they achieve inadequate urine concentrations despite systemic efficacy. 1, 3

• Do not use newer azoles (voriconazole, posaconazole) for urinary tract infections, as they also fail to achieve adequate urinary drug levels. 3

• Do not rely on colony counts or degree of pyuria to distinguish colonization from infection; the presence of urinary symptoms is the key determinant. 2, 4

• Do not dismiss candiduria in males as simple colonization, as anatomic factors (prostate, longer urethra) make true infection more likely than in catheterized females. 1

Follow-Up and Monitoring

• Reassess clinical response within 48–72 hours of initiating fluconazole therapy. 2

• No routine follow-up urine culture is needed if symptoms resolve completely with treatment. 2

• If symptoms persist or recur, obtain repeat urine culture with antifungal susceptibility testing to identify resistant species. 2, 3

• Evaluate for underlying urologic abnormalities (strictures, stones, prostatic disease) if candiduria recurs after appropriate treatment. 1, 2

Special Considerations for This Patient

• All urinary tract infections in men are classified as complicated and require a minimum of 7 days of therapy, but 14 days is preferred for fungal infections. 5, 2

• Evaluate for diabetes mellitus if not already known, as uncontrolled hyperglycemia is a major risk factor for candiduria and treatment failure. 2, 6

• Consider prostate involvement (Candida prostatitis) if symptoms persist despite appropriate therapy, as this requires prolonged treatment (4–6 weeks). 2, 4