How should I manage a patient with candiduria that shows hyphal forms of yeast in the urine, especially if they have an indwelling urinary catheter or are asymptomatic?

Management of Candiduria with Hyphal Forms

Remove the indwelling urinary catheter immediately if present—this single intervention clears candiduria in approximately 50% of cases without any antifungal therapy—and treat with antifungals only if the patient is symptomatic or belongs to a high-risk group (neutropenic, very low birth weight neonate, or undergoing urologic procedures). 1

Clinical Significance of Hyphae in Urine

• The presence of hyphal forms (pseudohyphae or true hyphae) on urinalysis does not change the fundamental management approach, as both budding yeast and hyphae represent Candida colonization in asymptomatic patients. 1
• Candiduria progresses to candidemia in less than 5% of cases, serving primarily as a marker of illness severity rather than a cause of morbidity itself. 1
• Treatment of asymptomatic candiduria does not reduce mortality rates or improve clinical outcomes in most patient populations. 1

Algorithmic Approach to Management

Step 1: Determine if Patient is Symptomatic

Asymptomatic patients (no dysuria, frequency, urgency, flank pain, fever, or systemic signs):

• Do not treat with antifungals unless they fall into high-risk categories below. 1
• Remove the indwelling catheter immediately—this resolves candiduria in ~50% without medication. 1
• Discontinue unnecessary broad-spectrum antibiotics. 1

Symptomatic patients (dysuria, frequency, urgency, suprapubic pain, or fever):

• Proceed directly to antifungal therapy as outlined in Step 3. 1

Step 2: Identify High-Risk Patients Requiring Treatment Despite Being Asymptomatic

Treat asymptomatic candiduria only in these specific populations:

• Neutropenic patients with persistent unexplained fever and candiduria—risk of disseminated candidiasis mandates aggressive treatment. 1
• Very low birth weight neonates (typically <1500 g)—high propensity for invasive candidiasis. 1
• Patients undergoing urologic procedures or instrumentation within the next several days—to prevent procedure-related candidemia. 1
• Patients with urinary tract obstruction that cannot be promptly relieved. 1

Step 3: Antifungal Treatment Regimens

For Symptomatic Cystitis (Lower UTI)

• Fluconazole 200 mg (≈3 mg/kg) orally once daily for 14 days is first-line therapy for fluconazole-susceptible species—this is based on the only randomized, double-blind, placebo-controlled trial demonstrating efficacy. 1
• Fluconazole achieves high urinary concentrations that reliably eradicate the pathogen. 1

For Symptomatic Pyelonephritis (Upper UTI)

• Fluconazole 200–400 mg (≈3–6 mg/kg) orally once daily for 14 days—use the higher 400 mg dose when upper-tract involvement is confirmed by flank pain, fever >38.3°C, or imaging. 1

For Fluconazole-Resistant Species (Candida glabrata or C. krusei)

• 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
• 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
• Obtain species identification and susceptibility testing before initiating therapy, as Nakaseomyces (formerly C. glabrata) frequently exhibits fluconazole resistance. 2

For Patients Undergoing Urologic Procedures

• Fluconazole 200–400 mg daily for several days before and after the procedure to prevent procedure-related candidemia. 1

Step 4: Essential Non-Pharmacologic Interventions

• Immediate catheter removal is the single most important intervention—continuing catheters is the most common cause of treatment failure. 1
• Eliminate urinary tract obstruction to facilitate infection clearance. 1
• Remove or replace nephrostomy tubes or ureteral stents when present to reduce fungal burden. 1

Critical Pitfalls to Avoid

• Do not treat asymptomatic candiduria reflexively in otherwise healthy individuals, diabetic patients without other high-risk features, or elderly patients—these are risk factors but not indications for treatment. 1
• Do not use echinocandins (caspofungin, micafungin, anidulafungin) or newer azoles (voriconazole, posaconazole) for urinary Candida infections—they achieve inadequate urine concentrations. 1, 3
• Do not rely on colony counts or pyuria to distinguish colonization from infection, especially in catheterized patients—these markers are unreliable. 1
• Do not use lipid formulations of amphotericin B for Candida urinary tract infections—they do not attain adequate urinary levels. 1
• In male patients, do not automatically dismiss candiduria as simple colonization—evaluate for possible prostatitis if urinary symptoms develop. 1

Complicated Infections Requiring Surgical Intervention

• Fungal balls (bezoars) or obstructive uropathy mandate surgical or endoscopic removal plus systemic antifungal therapy—antifungal agents alone fail without drainage. 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

Follow-Up and Recurrence

• For recurrent candiduria after appropriate therapy, evaluate for underlying urologic abnormalities such as strictures, stones, prostatic disease, or persistent obstruction. 1
• Obtain follow-up urine cultures to document clearance after completing therapy; if treatment fails, obtain imaging to identify fungus balls, hydronephrosis, abscesses, or structural abnormalities. 2