From the Guidelines
The next step for this 85-year-old afebrile man with a chronic suprapubic tube and persistent Candida in his urine culture (>100,000 CFU) despite tube change is to initiate antifungal therapy with oral fluconazole 400 mg on day 1, followed by 200 mg daily for 14 days. Since the patient is afebrile and likely has fungal colonization rather than invasive infection, this regimen should be sufficient to clear the funguria. If the patient has renal impairment, the dose should be adjusted accordingly. Alternative options include amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) if oral therapy is contraindicated. It's essential to monitor renal function during treatment and repeat a urine culture after completing therapy to confirm clearance. Persistent funguria in patients with indwelling urinary catheters is common, and treatment is indicated in this case because the high colony count persisted despite changing the suprapubic tube, suggesting true infection rather than simple colonization. If fluconazole treatment fails, susceptibility testing should be performed to guide alternative antifungal selection 1, 2.
Some key points to consider in this case include:
- The patient's age and the presence of a chronic suprapubic tube increase the risk of complications from untreated funguria.
- The high colony count of Candida in the urine culture suggests true infection rather than simple colonization.
- Antifungal therapy with fluconazole is a reasonable first-line treatment option, but alternative options such as amphotericin B bladder irrigation may be necessary in some cases.
- Monitoring renal function during treatment and repeating a urine culture after completing therapy are crucial to ensure clearance of the infection.
- The provided evidence 1, 2 focuses on bacterial urinary tract infections, but the principles of treating persistent infection and monitoring for clearance can be applied to fungal infections as well.
From the Research
Patient Profile
- 85-year-old febrile man with a chronic suprapubic tube
- Greater than 100,000 CFU/mL on urine culture
- Fungi persist after suprapubic tube change
Next Steps
- According to 3 and 4, the presence of Candida species in urine in asymptomatic patients does not warrant antifungal therapy, except in certain cases such as neutropenic patients or those undergoing urologic procedures
- However, since the patient is febrile and has a high fungal count, treatment may be necessary
- Fluconazole is the treatment of choice for symptomatic infections, as it achieves high urinary levels 3, 4
- Alternative treatment options include amphotericin B deoxycholate 3 or amphotericin B bladder irrigations (ABBI) 5
- ABBI may be considered an alternative to fluconazole, especially in patients with renal dysfunction 5
Considerations
- Removing predisposing factors, such as indwelling catheters and antibiotics, may clear candiduria in almost 50% of asymptomatic patients 4
- Antifungal susceptibility tests should be applied with identification of species for effective treatment 6
- The choice of treatment should be based on the severity of the infection, the patient's underlying medical conditions, and the susceptibility of the fungal isolate to antifungal agents 6, 5