Treatment of Asymptomatic Candida glabrata UTI
Asymptomatic Candida glabrata candiduria in a non-immunocompromised patient without an indwelling catheter or recent urologic manipulation does NOT require antifungal treatment. 1
Evidence-Based Rationale
The IDSA guidelines explicitly state that therapy of asymptomatic candiduria in the non-neutropenic, non-catheterized patient has never been shown to be of value. 2 This recommendation is grounded in several key observations:
- Candiduria progresses to candidemia in less than 5% of cases, making it primarily a marker of illness severity rather than a cause of morbidity itself. 1
- Treatment does not reduce mortality rates in asymptomatic patients. 1
- In most patients, isolation of Candida represents only colonization and is a benign event. 2
- A placebo-controlled trial demonstrated that while fluconazole hastened time to negative urine culture, 2 weeks after therapy ended, the frequency of negative cultures was identical between treatment and placebo groups (∼73% for non-catheterized patients). 2
When Treatment IS Indicated (High-Risk Exceptions)
Even in asymptomatic patients, antifungal therapy is mandatory in these specific populations:
- Neutropenic patients with persistent unexplained fever and candiduria—due to heightened risk of disseminated candidiasis. 2, 1
- Very low birth weight neonates (<1500 g)—because of high propensity for invasive disease. 1
- Patients undergoing urologic procedures or instrumentation within several days—to prevent procedure-related candidemia. 1
- Patients with urinary tract obstruction that cannot be promptly relieved—as obstruction sustains fungal persistence. 1
Management Algorithm for Your Patient
Since your patient is:
- Asymptomatic
- Non-immunocompromised
- Without indwelling catheter
- Without recent urologic manipulation
The recommended approach is observation only. 1
Non-Pharmacologic Measures (If Risk Factors Present)
- Discontinue any unnecessary broad-spectrum antibiotics, as these are major risk factors for candiduria development. 1
- Evaluate for and correct any underlying urinary tract abnormalities (strictures, stones, prostatic disease) if candiduria recurs. 1
Species-Specific Considerations for C. glabrata
While C. glabrata is often fluconazole-resistant 3, 4, this resistance profile is irrelevant in asymptomatic patients who do not require treatment. The resistance pattern only becomes clinically significant if the patient develops:
- Symptomatic cystitis (dysuria, frequency, urgency)
- Pyelonephritis (flank pain, fever >38.3°C)
- Falls into a high-risk category requiring treatment
In those scenarios, C. glabrata would require 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 instead of fluconazole. 1
Critical Pitfalls to Avoid
- Do not reflexively treat asymptomatic candiduria simply because the organism is isolated—most cases represent benign colonization. 1
- Do not assume diabetes mellitus or advanced age alone mandates therapy—these are risk factors for candiduria but not indications for treatment in asymptomatic patients. 1
- Do not rely on colony counts or pyuria to differentiate colonization from infection, especially in catheterized patients—these markers are unreliable. 1
- Avoid echinocandins and newer azoles (voriconazole, posaconazole) for urinary Candida infections if treatment ever becomes necessary—they achieve inadequate urine concentrations. 4, 5
When to Reassess
Monitor for development of:
- Urinary symptoms (dysuria, frequency, urgency, suprapubic pain)
- Systemic signs (fever, flank pain)
- New immunosuppression or neutropenia
- Planned urologic procedures
Any of these developments would trigger reassessment for antifungal therapy. 1