From the Guidelines
The next step for this 85-year-old afebrile male with persistent Candida in the urine despite suprapubic tube exchange is oral fluconazole (option D).
Reasons for Recommendation
- Fluconazole is typically given at a dose of 200-400 mg initially, followed by 100-200 mg daily for 7-14 days for treatment of funguria that persists after catheter exchange, as recommended by the Infectious Diseases Society of America 1.
- Since the patient has already had the suprapubic tube exchanged without resolution of the funguria, antifungal therapy is now indicated.
- Fluconazole is preferred because it achieves good urinary concentrations and is effective against most Candida species.
- Treatment is warranted in this case because persistent funguria in a patient with urinary tract hardware (the suprapubic tube) increases the risk of ascending infection and potential complications.
Considerations
- Simply monitoring with repeat cultures or imaging studies would not address the active infection, and fungal blood cultures would only be indicated if there were signs of systemic infection, which this afebrile patient does not demonstrate.
- Flucytosine is generally reserved for more resistant cases or used in combination therapy for severe infections, as noted in previous guidelines 1.
Key Points
- The patient's age and presence of a suprapubic tube increase the risk of complications from persistent funguria.
- Fluconazole is a well-established treatment for candiduria, with a favorable safety profile and good efficacy against most Candida species.
- The dose and duration of fluconazole treatment may need to be adjusted based on the patient's renal function and response to therapy.
From the FDA Drug Label
For the treatment of Candida urinary tract infections and peritonitis, daily doses of 50 to 200 mg have been used in open, noncomparative studies of small numbers of patients. The next step is to treat the patient with oral fluconazole.
- The dosage for Candida urinary tract infections is not explicitly stated, but based on the information provided, a daily dose of 50 to 200 mg can be considered. 2
From the Research
Next Steps in Management
The patient has an 85-year-old afebrile male with a chronic suprapubic tube and Candida on a urine culture, and the funguria persists after suprapubic tube exchange. The next steps in management are:
- Evaluate the patient for symptoms of Candida urinary tract infection, such as cystitis, pyelonephritis, prostatitis, or epididymo-orchitis 3
- Verify funguria by repeating the urinalysis and urine culture 4
- Consider imaging studies, such as ultrasonography of the kidneys and collecting systems, to evaluate for complications such as pyelonephritis or perinephric abscess 4
- Consider antifungal therapy, such as fluconazole, if the patient is symptomatic or has a high risk of complications 3, 5, 6
Diagnostic Considerations
- Pyuria is a nonspecific finding, and the morphology of the offending yeast may allow separation of Candida glabrata from other species 4
- Candida casts in the urine are indicative of renal candidiasis but are rarely seen 4
- Colony counts have not proved to be diagnostically useful 4
Treatment Options
- Fluconazole is the treatment of choice for symptomatic infections, and it achieves high urinary levels 3, 5, 6
- Amphotericin B deoxycholate is an alternative antifungal agent if fluconazole cannot be used due to resistance, allergy, or failure 3
- Fluconazole irrigation may be effective in eradicating Candida from the urine in patients with a permanent nephrostomy or suprapubic catheter 7