What is the recommended duration of fluconazole treatment for fluconazole‑susceptible Candida pyelonephritis in a patient with an indwelling ureteral stent?

Duration of Fluconazole Treatment for Candida Pyelonephritis with Indwelling Ureteral Stent

For fluconazole-susceptible Candida pyelonephritis in a patient with an indwelling ureteral stent, treat with fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks, and the stent must be removed or replaced as soon as clinically feasible. 1

Treatment Duration and Dosing

• Standard duration is 2 weeks (14 days) of fluconazole therapy for Candida pyelonephritis caused by fluconazole-susceptible organisms 1
• Dosing: Fluconazole 200-400 mg daily (or 3-6 mg/kg daily) is the recommended regimen 1
• Treatment should continue until symptoms resolve and urine cultures become negative 1

Critical Management of the Indwelling Stent

• Removal or replacement of the ureteral stent is mandatory and represents a critical component of successful treatment 1, 2, 3
• Failure to remove or replace indwelling devices is a major pitfall that leads to treatment failure and recurrent infection 2, 3
• The stent acts as a nidus for persistent fungal colonization and biofilm formation, making eradication difficult even with appropriate antifungal therapy 2

Additional Management Considerations

Urinary Tract Obstruction

• Eliminate any urinary tract obstruction if present, as this is strongly recommended for successful treatment 1, 3
• Imaging of the genitourinary tract should be performed to identify and address any anatomical issues 1

Species-Specific Considerations

• This 2-week duration applies specifically to fluconazole-susceptible species such as Candida albicans, C. tropicalis, and C. parapsilosis 1, 4
• For fluconazole-resistant organisms (particularly C. glabrata or C. krusei), alternative agents are required: amphotericin B deoxycholate 0.5-0.7 mg/kg daily with or without flucytosine 25 mg/kg four times daily for 2 weeks 1, 3

Monitoring and Follow-Up

• Obtain follow-up urine cultures to document clearance of infection 2, 3
• Monitor for clinical resolution of symptoms including fever, flank pain, and dysuria 1
• If candidemia is suspected or documented, treat as disseminated candidiasis with longer duration and higher intensity therapy 1, 2

Common Pitfalls to Avoid

• Do not continue treatment without addressing the stent: Leaving the device in place is associated with high rates of treatment failure and recurrence 2, 3
• Do not use echinocandins for urinary tract infections, as they achieve minimal urinary concentrations and are ineffective for this indication 3
• Do not extend treatment beyond 2 weeks in uncomplicated cases once symptoms resolve and cultures clear, as this does not improve outcomes 1, 5
• Do not use lipid formulations of amphotericin B for urinary tract infections, as they do not achieve adequate urine levels 3

When to Consider Longer Duration

• If the stent cannot be removed due to clinical necessity, consider longer suppressive therapy until removal is feasible, though specific duration data for this scenario are limited 1
• For patients with persistent positive cultures despite 2 weeks of therapy and stent removal, extend treatment and investigate for complications such as fungus balls or perinephric abscess 1