What is the recommended treatment for a patient with candiduria?

Treatment of Candiduria (Fungus in the Urine)

For most patients with candiduria, the first and most important intervention is removal of the indwelling urinary catheter—this alone clears candiduria in approximately 50% of cases without any antifungal therapy. 1

Asymptomatic Candiduria: Observation Without Treatment

Asymptomatic candiduria should not be treated in the vast majority of patients, as it represents benign colonization rather than infection and treatment does not reduce mortality or improve outcomes. 2, 1

• Candiduria progresses to candidemia in less than 5% of cases, making it primarily a marker of illness severity rather than a cause of morbidity. 1, 3
• A randomized placebo-controlled trial demonstrated that fluconazole accelerates clearance initially, but two weeks after stopping therapy, candiduria rates are identical between treated and untreated groups (approximately 73% clearance in non-catheterized patients). 1, 4
• Removing predisposing factors—particularly indwelling catheters and unnecessary broad-spectrum antibiotics—clears candiduria in nearly 50% of asymptomatic patients without antifungal drugs. 2, 1

High-Risk Exceptions Requiring Treatment Despite Lack of Symptoms

Even without urinary symptoms, antifungal therapy is mandatory in these specific populations:

• Neutropenic patients with persistent unexplained fever and candiduria—treat as candidemia to prevent disseminated infection. 1, 3
• Very low birth weight neonates (typically <1500 g) due to high risk of invasive candidiasis. 1, 3
• Patients undergoing urologic procedures or instrumentation within several days—give fluconazole 200–400 mg daily for several days before and after the procedure. 1, 3
• Patients with urinary tract obstruction that cannot be promptly relieved. 3

Symptomatic Candiduria: Antifungal Treatment Required

Candida Cystitis (Lower Urinary Tract Infection)

For symptomatic cystitis (dysuria, frequency, urgency, suprapubic pain) caused by fluconazole-susceptible Candida species, fluconazole 200 mg (approximately 3 mg/kg) orally once daily for 14 days is the first-line treatment. 2, 1, 3

• This recommendation is based on the only randomized, double-blind, placebo-controlled trial demonstrating efficacy. 1
• Fluconazole achieves high urinary concentrations of active drug, ensuring effective pathogen eradication. 1, 5
• Catheter removal remains essential even when treating symptomatic infection—continuing catheters is the most common cause of treatment failure. 1, 6

Candida Pyelonephritis (Upper Urinary Tract Infection)

For symptomatic pyelonephritis (flank pain, fever >38.3°C, systemic symptoms) with fluconazole-susceptible organisms, fluconazole 200–400 mg (3–6 mg/kg) orally once daily for 14 days is recommended, using the higher 400 mg dose when upper-tract involvement is confirmed. 2, 1, 3

• If symptoms persist beyond 48–72 hours, obtain renal or bladder imaging (ultrasound or CT) to exclude obstruction, fungal balls, or perinephric abscesses. 1

Fluconazole-Resistant Species: Alternative Regimens

Candida glabrata (Often Fluconazole-Resistant)

For C. glabrata cystitis or pyelonephritis, 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 for 7–10 days. 1, 3

• Oral flucytosine monotherapy (25 mg/kg four times daily for 7–10 days) may be considered when amphotericin B is unsuitable, though this is a weaker recommendation. 1

Candida krusei (Intrinsically Fluconazole-Resistant)

For C. krusei infections, amphotericin B deoxycholate 0.3–0.6 mg/kg IV daily for 1–7 days is the treatment of choice. 1, 3

Bladder Irrigation for Refractory Cystitis

• Amphotericin B deoxycholate bladder irrigation (50 mg/L sterile water daily for 5 days) can be employed for refractory fluconazole-resistant cystitis, though relapse rates are high (80–90%). 2, 1

Complicated Infections: Fungal Balls and Obstruction

Fungal balls (bezoars) or casts in the renal pelvis or bladder require surgical or endoscopic removal in addition to systemic antifungal therapy—antifungal agents alone fail without drainage. 2, 1

• For patients with nephrostomy tubes, adjunctive irrigation with amphotericin B deoxycholate 25–50 mg diluted in 200–500 mL sterile water is recommended as a complement to systemic treatment. 1

Critical Pitfalls to Avoid

• Do not use echinocandins (caspofungin, micafungin, anidulafungin) or newer azoles (voriconazole, posaconazole) for urinary Candida infections—they achieve inadequate urine concentrations. 2, 5
• Do not use lipid formulations of amphotericin B for Candida urinary tract infections—they do not attain adequate urinary levels. 1
• Do not rely on colony counts or pyuria to differentiate colonization from infection, especially in catheterized patients. 2, 1
• In male patients, do not dismiss candiduria as simple colonization—anatomical factors (prostate, longer urethra) increase the likelihood of true infection requiring evaluation for prostatitis. 1
• For recurrent candiduria after appropriate therapy, evaluate for underlying urologic abnormalities such as strictures, stones, prostatic disease, or persistent obstruction. 1