Candiduria: Should we treat, when and how? Hail M. Al-Abdely, MD Consultant Infectious Diseases King Faisal Specialist Hospital & Research Center

Candiduria: Should we Candiduria: Should we treat, when and how?treat, when and how?

Hail M. Al-Abdely, MDHail M. Al-Abdely, MDConsultant Infectious DiseasesConsultant Infectious DiseasesKing Faisal Specialist Hospital & King Faisal Specialist Hospital &

Research CenterResearch Center

Presentation OutlinePresentation Outline

How common is this problem? How common is this problem? Who gets it?Who gets it? Why do we get candiduria?Why do we get candiduria? Why should we treat it?Why should we treat it? Who should be treated? and who should Who should be treated? and who should

not?not? How to treat candiduria?How to treat candiduria? What are the current recommendations in What are the current recommendations in

the management of candiduria?the management of candiduria?

Funguria or CandiduriaFunguria or Candiduria

Candiduria = 99% of FunguriaCandiduria = 99% of Funguria

How common is How common is Candiduria?Candiduria?

How common is this problem?How common is this problem? 1910: Raffin was the first to report candiduria1910: Raffin was the first to report candiduria

1946: first well-documented case of candiduria. 1946: first well-documented case of candiduria. Moulder MK. J Urol 1946, 56:420-426Moulder MK. J Urol 1946, 56:420-426

1957: Cross-sectional study 1957: Cross-sectional study • Candiduria in only 15 of 1500 patients. Candiduria in only 15 of 1500 patients. • More than 50% of these 15 patients had diabetes mellitus and More than 50% of these 15 patients had diabetes mellitus and

were receiving antibiotics. were receiving antibiotics. Guze LB, Harley LD: Guze LB, Harley LD: Yale J Biol Med Yale J Biol Med 1957, 1957, 30:292–30530:292–305

1972: In a prospective study of healthy adults1972: In a prospective study of healthy adults• Urine cultures were positive in 10 of 440Urine cultures were positive in 10 of 440• Culture results reverted to negative when clean catch Culture results reverted to negative when clean catch

techniques were used techniques were used Schonebeck J, Ansehn S: Schonebeck J, Ansehn S: Scand J Urol Nephrol Scand J Urol Nephrol 1972, 6:123–1281972, 6:123–128

From 1980-1990 the nosocomial fungal infection rate for urinary tract infections had risen from 9.0 to 20.5 per 10,000 hospitalized patients

Nosocomial bacteriuria or candiduria develops in up to 25% of patients requiring a urinary catheter for >7 days, with a daily risk of 5%

Candida species are now the commonest organisms isolated from urine specimens in surgical ICU patients.

How common is Candiduria?How common is Candiduria?

Maki DG, Tambyah PA. 2001 Emerg Infect Dis;7:342-7

Lundstrom T, Sobel J. Clin Infect Dis. 2001 ;32:1602-7

Hospital wideHospital wide Intensive care unitsIntensive care units

PathogensPathogens (% of total)(% of total) (% of total)(% of total)

Escherichia coli 26 18

Enterococci 16 13

Pseudomonas aeruginosa 12 11

Klebsiella and Enterobacter 12 13

Candida spp. 9 25

Microbial pathogens causing nosocomial catheter-Microbial pathogens causing nosocomial catheter-associated urinary tract infections in U.S. acute-care associated urinary tract infections in U.S. acute-care

hospitals, 1990-92hospitals, 1990-92

Jarvis WR, Martone WJ. J Antimicrob Chemother 1992;29:19-24.

Who gets Candiduria?Who gets Candiduria?

Who gets it?Who gets it? Diabetes mellitusDiabetes mellitus AntibioticsAntibiotics Indwelling urinary cathetersIndwelling urinary catheters Other risk factors. Other risk factors.

• Extremes of age Extremes of age • Female sex Female sex • Immunosuppressive agents Immunosuppressive agents • Use of iv cathetersUse of iv catheters• Interruption of the flow of urineInterruption of the flow of urine• Radiation therapy Radiation therapy

Hamory BH. J Urol 1978, 120:444-448 Platt R, et al. Am J Epidemiol 1986, 124:977-985Storfer SP, et al. Infect Dis Clin Pract 1994, 3:23-29Phillips JR. Pediatr Infec Dis 1997, 16:190-194

Clin Infect Dis Clin Infect Dis 2000, 30:14–182000, 30:14–18

Prospective Multicenter Surveillance Study of Funguria Prospective Multicenter Surveillance Study of Funguria in Hospitalized Patientsin Hospitalized Patients

Study design: Study design: • Prospective “observational” multicenter study• No attempt was made to influence physicians' responses

to the report of a urine culture yielding yeast. • Patients were followed until their discharge from the

hospital or for a maximum of 10 weeks.

• Underlying conditions.• Urinary tract instrumentation.• Symptoms and signs of infection.• Urinalysis results.• Organisms isolated.• Treatment.• Outcomes.

Underlying disease or conditionUnderlying disease or condition No. (%) of patientsNo. (%) of patients

Surgical procedureSurgical procedure 450 (52.3)450 (52.3)

Diabetes mellitusDiabetes mellitus 336 (39)336 (39)

Urinary tract diseaseUrinary tract disease 325 (37.7)325 (37.7)

Neurogenic bladder Neurogenic bladder

Prostatism, stones, or other obstructing lesionsProstatism, stones, or other obstructing lesions

Renal failureRenal failure

Recurrent infectionRecurrent infection

Intrinsic renal diseaseIntrinsic renal disease

105 (12.2)105 (12.2)

100 (11.6)100 (11.6)

65 (7.5) 65 (7.5)

32 (3.7) 32 (3.7)

23 (2.7)23 (2.7)

MalignancyMalignancy 191 (22.2)191 (22.2)

MalnutritionMalnutrition 146 (17)146 (17)

TraumaTrauma 59 (6.9)59 (6.9)

NeutropeniaNeutropenia 37 (4.3)37 (4.3)

TransplantTransplant 30 (3.5)30 (3.5)

NoneNone 94 (10.9)94 (10.9)

Underlying diseases or conditions in 861 Underlying diseases or conditions in 861 patients with funguria.patients with funguria.

Kauffman CA, et al. Clin Infect Dis 2000, 30:14–18.

Device or procedureDevice or procedure No. (%) of patientsNo. (%) of patients

Indwelling urethral catheterIndwelling urethral catheter 668 (77.6)668 (77.6)

Intermittent urethral catheterizationIntermittent urethral catheterization 40 (4.6)40 (4.6)

Suprapubic catheterSuprapubic catheter 19 (2.2)19 (2.2)

Nephrostomy drainageNephrostomy drainage 19 (2.2)19 (2.2)

Ileal conduitIleal conduit 9 (1)9 (1)

Ureteral stentUreteral stent 10 (1.2)10 (1.2)

NoneNone 145 (16.8)145 (16.8)

Urinary drainage devices in and procedures Urinary drainage devices in and procedures undergone by 861 patients with funguriaundergone by 861 patients with funguria


Yeast isolatesYeast isolates No. (%) of patientsNo. (%) of patients

Candida albicans 446 (51.8)

Candida glabrata 134 (15.6)

Candida tropicalis 68 (7.9)

Candida parapsilosis 35 (4.1)

Candida krusei 9 (1)

Other 20 (2.3)

Undetermined 184 (21.4)

Initial yeast isolates from urine 861 Initial yeast isolates from urine 861 patients with funguriapatients with funguria


Why do we get Why do we get candiduria?candiduria?

Why do we get candiduria?Why do we get candiduria?

Defense mechanisms against Defense mechanisms against development of candiduria?development of candiduria?• Flushing effect of urineFlushing effect of urine

Normal urinary tract anatomyNormal urinary tract anatomy Normal urinary tract functionNormal urinary tract function

• Balanced distribution of perineal floraBalanced distribution of perineal flora Causes of breach of defense Causes of breach of defense

mechanisms?mechanisms?

Routes of entry of uro-pathogens to catheterized urinary tract Routes of entry of uro-pathogens to catheterized urinary tract

Maki DG, Tambyah PA. 2001 Emerg Infect Dis;7(2):342-7

Scanning electron micrograph of an infected catheter showing dense and complex biofilm on the extraluminal surface

Maki DG, Tambyah PA. 2001 Emerg Infect Dis;7(2):342-7

Stark RP, Maki DG. N Engl J Med 1984;311:560-4.

Why should we treat Why should we treat Candiduria?Candiduria?

Why should we treat it?Why should we treat it?

Symptomatic UTISymptomatic UTI Ascending infection.Ascending infection.

• Invasive cystitisInvasive cystitis• PyelonephritisPyelonephritis• Fungus ballFungus ball

Hematogenous spread.Hematogenous spread. • Invasive candidiasis/candidemiaInvasive candidiasis/candidemia

Candiduria as the only sign of invasive Candiduria as the only sign of invasive candidiasis/candidemiacandidiasis/candidemia

mycoses 42, 285–289 (1999)

Antifungal therapyAntifungal therapy No. (%) of patientsNo. (%) of patients

Fluconazole onlyFluconazole only 161 (18.7)161 (18.7)

Amphotericin B only Amphotericin B only

Bladder irrigation Bladder irrigation

IntravenouslyIntravenously

Intravenously and by bladderIntravenously and by bladder

irrigationirrigation

100 (11.6) 100 (11.6)

30 (3.5) 30 (3.5)

11 (1.3)11 (1.3)

Fluconazole and amphotericin BFluconazole and amphotericin B

Bladder irrigation Bladder irrigation

IntravenouslyIntravenously36 (4.2) 36 (4.2)

21 (2.4)21 (2.4)

OtherOther 11 (1.3)11 (1.3)

NoneNone 491 (57.0)491 (57.0)

Antifungal therapy for 861 patients with Antifungal therapy for 861 patients with funguriafunguria


Who is at risk of invasive Who is at risk of invasive candidiasis from candiduriacandidiasis from candiduria

• Patients with neutropeniaPatients with neutropenia

• Infants with low birth weightInfants with low birth weight

• Patients with renal allograft Patients with renal allograft

• ICU patients with multiple site colonizationICU patients with multiple site colonization

• Patients who will undergo urologic manipulationsPatients who will undergo urologic manipulations

• Patients with significant urinary tract obstructionPatients with significant urinary tract obstruction

Why should we Why should we notnot treat it? treat it?

Why should we Why should we notnot treat it? treat it?• Candiduria is discovered, rather than detected by deliberate Candiduria is discovered, rather than detected by deliberate

researchresearch• Problems with diagnosisProblems with diagnosis

Contamination:Contamination: • Urine specimens become contaminated with Urine specimens become contaminated with Candida Candida during during

the process of obtaining a urine the process of obtaining a urine • Vulvo-vestibular colonization with Vulvo-vestibular colonization with CandidaCandida (10% 65%) (10% 65%)

Colonization of the drainage deviceColonization of the drainage device• No reliable method for differentiating colonization from No reliable method for differentiating colonization from

infection.infection.• Asymptomatic adherence and settlement of yeast may result Asymptomatic adherence and settlement of yeast may result

in a high concentration of the organisms on urine culture in a high concentration of the organisms on urine culture

Infection Infection • Tissue invasion can not be determinedTissue invasion can not be determined• Pyuria and colony countsPyuria and colony counts

• Problems with outcome of TreatmentProblems with outcome of Treatment Benefits versus risksBenefits versus risks

Significance of High Colony Counts Significance of High Colony Counts and Pyuriaand Pyuria

1956: Edward Kass defined significant 1956: Edward Kass defined significant bacteruria as 100,000 cfu/ml. bacteruria as 100,000 cfu/ml. Kass EH: Kass EH: Trans Trans Assoc Am Physicians Assoc Am Physicians 1956, 69:56–641956, 69:56–64

1984: Stamm showed that cases of 1984: Stamm showed that cases of pyelonephritis and symptomatic cystitis pyelonephritis and symptomatic cystitis had bacterial counts <100,000. had bacterial counts <100,000. Stamm WE:Stamm WE: Eur J Clin Microbiol Eur J Clin Microbiol 1984, 1984, 3:3:279–281.279–281.

Problems:Problems: These definitions were conducted with E. coliThese definitions were conducted with E. coli Never obtained for patients with urinary cathetersNever obtained for patients with urinary catheters Never done with candidaNever done with candida Ability candida grow fast in urine can give high Ability candida grow fast in urine can give high

counts even from contaminated specimencounts even from contaminated specimen

Colony countsColony counts

Significance of High Colony Counts Significance of High Colony Counts and Pyuriaand Pyuria

Indicates “Indicates “inflammation”inflammation” along the urinary along the urinary tracttract

Coupled with significant colony count Coupled with significant colony count indicates indicates “infection”.“infection”.

Problems:Problems: Catheter irritation can cause pyuria and Catheter irritation can cause pyuria and

hematuriahematuria Co-existing bacterial pathogen is commonCo-existing bacterial pathogen is common

PyuriaPyuria

TreatmentTreatment

No. (%) of patients whose No. (%) of patients whose funguriafunguria

ResolvedResolved

((n n = 288)= 288)Persisted or Persisted or

recurredrecurred

((n n = 242)= 242)

NoneNone 117 (75.5)117 (75.5) 38 (24.5)38 (24.5)

Catheter removal onlyCatheter removal only 41 (35.3)41 (35.3) 75 (64.7)75 (64.7)

Antifungal drugs, with or without Antifungal drugs, with or without catheter removalcatheter removal

130 (50.2)130 (50.2) 129 (49.8)129 (49.8)

Outcome of funguria in 530 patients for Outcome of funguria in 530 patients for whom outcome was documentedwhom outcome was documented

Kauffman CA, Kauffman CA, et al.et al. Clin Infect Dis Clin Infect Dis 2000, 2000, 30:30:14–1814–18

Candidemia found in 7 (1.3%) patientsCandidemia found in 7 (1.3%) patients• All had intravascular catheters and multiple All had intravascular catheters and multiple

underlying diseasesunderlying diseases Five of 7 patients with candidemia diedFive of 7 patients with candidemia died

Two patients (0.4%) died because of Two patients (0.4%) died because of candidiasiscandidiasis

Candidemia in 861 patients with FunguriaCandidemia in 861 patients with Funguria

Kauffman CA, Kauffman CA, et al.et al. Clin Infect Dis Clin Infect Dis 2000, 2000, 30:30:14–18.14–18.

Sobel JD, Sobel JD, et al.et al.: : Clin Infect Dis Clin Infect Dis 2000, 31:209–2102000, 31:209–210

Patients have 2 consecutive positive urine cultures for Patients have 2 consecutive positive urine cultures for yeast that were performed at least 24 h apart yeast that were performed at least 24 h apart

Candiduria was defined as the presence in both cultures of Candiduria was defined as the presence in both cultures of >1000 cfu/Ml. >1000 cfu/Ml.

Catheterized patients were eligible only if a follow-up Catheterized patients were eligible only if a follow-up culture was positive after removal or replacement of the culture was positive after removal or replacement of the catheter. catheter.

Asymptomatic candiduria was defined as absence of both Asymptomatic candiduria was defined as absence of both urinary symptoms and feverurinary symptoms and fever

Patients were stratified by catheterization statusPatients were stratified by catheterization status Treatment 400mg loading followed by 200mg QD for 13 Treatment 400mg loading followed by 200mg QD for 13

daysdays Urine cultures done at days 3, 7 & 14 and 2 wks after the Urine cultures done at days 3, 7 & 14 and 2 wks after the

end of Rxend of Rx

Sobel JD, et al.: Clin Infect Dis 2000, 30:19-24



MortalityMortality

12 in fluconazole group and 14 in 12 in fluconazole group and 14 in placebo group (P=0.69)placebo group (P=0.69)

No mortality was attributed to fungal No mortality was attributed to fungal infection or treatmentinfection or treatment

No cases of candidemiaNo cases of candidemia


How to treat candiduria?How to treat candiduria?

How to treat candiduria?How to treat candiduria?

Modify risk factorsModify risk factors

Medical therapyMedical therapy

Candiduria

Repeat microscopy and culture

No candidaAsymptomatic

(previously healthy)Asymptomatic(predisposed)

Unstable patients Symptomatic

StopLook for predisposing

condition

None foundPredisposing

Condition found

Manage predisposingcondition

Candiduria resolves Candiduria persists

Condition not serious Condition serious

Systemic antifungal

Systemic antifungalObservation

Adopted from: Fisher JF. Curr Infect Dis Reports 2000, 2:523-530Adopted from: Fisher JF. Curr Infect Dis Reports 2000, 2:523-530

PolyenesAmphotericin B (deoxycholate) - 1958Liposomal amphotericin B (AmBisome) - 1997Amphotericin Lipid Complex (ABLC) - 1996Amphotericin Colloidal Dispersion (ABCD) - 1996

AzolesMiconazole (intravenous) - 1979Ketoconazole (P.O) - 1981Fluconazole (P.O, intravenous) - 1990Itraconazole (capsule, solution, intravenous) – 1992Voriconazole (P.O, intravenous)-2002

OthersGriseofulvin - 19595-Flucytosine - 1972Terbinafine – 1996Caspofungin- 2001

Medical TherapyMedical Therapy

candiduria candiduria uncommon uncommon and benign,and benign,

NO Rx

1960s1960s

Evolution of Treatment of Evolution of Treatment of CandiduriaCandiduria

1970s1970s

Slightly more Slightly more commoncommon but benign, but benign, treatment treatment toxic (Am B, toxic (Am B, 5-FC). 5-FC).

No Rx

1980s1980s

More common More common but benign in but benign in most patients,most patients, imidazoles imidazoles are not are not effective. effective. Am B toxic, Am B toxic,

Rx: Bladder irrigation with Am B

1990s1990s

Common, Common, benign. benign. Fluc safe and Fluc safe and effective.effective.Infrequent iv Infrequent iv Am B Am B is safe.is safe.Rx: FLUC,

bladder irrigationIv Am B

20002000

Candiduria Candiduria revisited. revisited. Era of EBMEra of EBM

Rx:Rx:Selective Selective therapytherapy

Medical Therapy of Candiduria (1)Medical Therapy of Candiduria (1)

AzolesAzoles• FluconazoleFluconazole

Advantage: Safe, high concentration in urine and effective Advantage: Safe, high concentration in urine and effective when compared with other therapieswhen compared with other therapies

Disadvantage: Limited spectrum because of resistance. Disadvantage: Limited spectrum because of resistance. Effect is short-termEffect is short-term

• Itraconazole:Itraconazole: Advantage: broad-spectrumAdvantage: broad-spectrum Disadvantage: Unfavorable pharmacokinetics, no Disadvantage: Unfavorable pharmacokinetics, no

concentration in urine, limited data showed failuresconcentration in urine, limited data showed failures• Ketoconazole:Ketoconazole:

More or less like itraconazoleMore or less like itraconazole• Voriconazole:Voriconazole:

Advantage: broad-spectrumAdvantage: broad-spectrum Disadvantage: No data on efficacyDisadvantage: No data on efficacy


Amphotericin B-basedAmphotericin B-based

• Intravenous AmB deoxycholateIntravenous AmB deoxycholate Advantage: Broad-spectrum, prolonged concentration in Advantage: Broad-spectrum, prolonged concentration in

urineurine Disadvantage: toxicityDisadvantage: toxicity

• Topical AmB deoxycholate (bladder irrigation):Topical AmB deoxycholate (bladder irrigation): Advantage: broad-spectrum, low toxicityAdvantage: broad-spectrum, low toxicity Disadvantage: Local therapy of the bladderDisadvantage: Local therapy of the bladder

• Lipid formulations of AmB:Lipid formulations of AmB: Advantage: broad-spectrum, low toxicityAdvantage: broad-spectrum, low toxicity Disadvantage: No concentration in urine. Reports of many Disadvantage: No concentration in urine. Reports of many

failuresfailures


OthersOthers

• 5-Flucytosine5-Flucytosine Advantage: High concentration in urine, covers non-Advantage: High concentration in urine, covers non-

albicans Candidaalbicans Candida Disadvantage: Resistance and toxicityDisadvantage: Resistance and toxicity

• Caspofungin:Caspofungin: Advantage: broad-spectrumAdvantage: broad-spectrum Disadvantage: No dataDisadvantage: No data

• Terbinafine:Terbinafine: No dataNo data

The main therapeutic modalitiesThe main therapeutic modalities• Systemic FluconazoleSystemic Fluconazole

Variable durationVariable duration

• Systemic Amphotericin BSystemic Amphotericin B Short durationShort duration

• Topical Amphotericin B (Bladder irrigation)Topical Amphotericin B (Bladder irrigation) Short durationShort duration Continuous Continuous Intermittent with catheter clampingIntermittent with catheter clamping


Oral fluconazole compared with bladder irrigation with amphotericin B Oral fluconazole compared with bladder irrigation with amphotericin B for treatment of fungal urinary tract infections in elderly patientsfor treatment of fungal urinary tract infections in elderly patients

Jacobs et al.Jacobs et al. Clin Infect Dis 1996, 22:30–35Clin Infect Dis 1996, 22:30–35

Prospective randomized trialProspective randomized trial Elderly >65 yearsElderly >65 years Stratified by presence of indwelling urinary catheterStratified by presence of indwelling urinary catheter Fluconazole 200mg loading them 100mg QD for 4 Fluconazole 200mg loading them 100mg QD for 4

days days versusversus AmB (5mg/ml) continuous bladder AmB (5mg/ml) continuous bladder irrigation for 5 daysirrigation for 5 days

109 (50 fluc versus 59 AmB irrigation)109 (50 fluc versus 59 AmB irrigation) Outcome: Outcome:

• Eradication at 2 days after therapyEradication at 2 days after therapy FindingsFindings

• Same baseline characteristicsSame baseline characteristics

Jacobs et al. Clin Infect Dis 1996, 22:30–35Jacobs et al. Clin Infect Dis 1996, 22:30–35

Study arms (each 30 adult patients who has 1000cfu/ml Study arms (each 30 adult patients who has 1000cfu/ml candiduria in 2 consecutive cultures)candiduria in 2 consecutive cultures)

1.1. Untreated controlsUntreated controls

2.2. Fluconazole: 200mg oral single dose followed by 100mg QD for 3 Fluconazole: 200mg oral single dose followed by 100mg QD for 3 daysdays

3.3. Iv Am B (15mg single dose)Iv Am B (15mg single dose)

4.4. Am B bladder irrigation for 3 days (5 mcg/ml intermittent Q8hrs)Am B bladder irrigation for 3 days (5 mcg/ml intermittent Q8hrs)



Outcome measure:Outcome measure:• Clearance of candiduria at day 1 and day 7Clearance of candiduria at day 1 and day 7

Clearance of funguria with short-course antifungalClearance of funguria with short-course antifungalregimens: a prospective, randomized, controlled studyregimens: a prospective, randomized, controlled study

Leu H-S, et al. Clin Infect Dis Leu H-S, et al. Clin Infect Dis 1995, 20:1152–11571995, 20:1152–1157

Clearance of funguria with short-course antifungalClearance of funguria with short-course antifungalregimens: a prospective, randomized, controlled studyregimens: a prospective, randomized, controlled study

Leu H-S, et al. Clin Infect Dis Leu H-S, et al. Clin Infect Dis 1995, 20:1152–11571995, 20:1152–1157

TreatmentsTreatments Clearance–Day 1Clearance–Day 1

No. (%)No. (%)Clearance-Day 7Clearance-Day 7

No. (%)No. (%)

Untreated controlsUntreated controls

No.=30No.=30-- 12/30 (40.0)12/30 (40.0)

FluconazoleFluconazole

No.=30No.=3017/29 (58.6)17/29 (58.6) 17/22 (77.3)17/22 (77.3)

Iv Am B (single dose)Iv Am B (single dose)

No.=30No.=3016/29 (55.2)16/29 (55.2) 18/25 (72.0)18/25 (72.0)

Am B bladder irrigation Am B bladder irrigation (5mcg/ml)(5mcg/ml)

No.=30No.=30

23/28 (82.1)23/28 (82.1) 9/21 (42.9)9/21 (42.9)


No.=30No.=30

26/30 (86.7)26/30 (86.7) 13/19 (68.4)13/19 (68.4)


No.=30No.=30

25/30 (83.3)25/30 (83.3) 15/22 (68.2)15/22 (68.2)

Treatment of urinary Fungus BallTreatment of urinary Fungus Ball

Occurs mainly with obstructive Occurs mainly with obstructive uropathyuropathy

Evidence comes only from anecdotal Evidence comes only from anecdotal reports.reports.• Surgical evacuationSurgical evacuation• Irrigation of antifungal agents through Irrigation of antifungal agents through

nephrostomy tubesnephrostomy tubes Amphotericin BAmphotericin B FluconazoleFluconazole 5-flucytosine5-flucytosine

IDSA Recommendations (1)IDSA Recommendations (1) Asymptomatic candiduria rarely requires therapy.

Candiduria may, however, be the only microbiological documentation of disseminated candidiasis.

Candiduria should be treated in • symptomatic patients, • patients with neutropenia, • infants with low birth weight• patients with renal allografts• Patients who will undergo urologic manipulations

Short courses of therapy are not recommended; therapy for 7–14 days is more likely to be successful.

Removal of urinary tract instruments or placement of new devices may be beneficial.

Treatment with fluconazole (200 mg/day for 7–14 days) and with amphotericin B deoxycholate at widely ranging doses (0.3–1.0 mg/kg per day for 1–7 days) has been successful.

Oral flucytosine (25 mg/kg q.i.d.) may be valuable for eradicating candiduria in patients with urologic infection due to non-albicans species of Candida.

Bladder irrigation with amphotericin B deoxycholate (50–200 mcg/mL) may transiently clear funguria but is rarely indicated

Even with apparently successful local or systemic antifungal therapy for candiduria, relapse is frequent, and this likelihood is increased by continued use of a urinary catheter.

Persistent candiduria in immunocompromised patients warrants ultrasonography or CT of the kidney

IDSA Recommendations (2)IDSA Recommendations (2)

ConclusionConclusion Generally candiduria is a benign condition that almost always Generally candiduria is a benign condition that almost always

associated with urinary instrumentation and may not warrant therapyassociated with urinary instrumentation and may not warrant therapy

Treatment of asymptomatic candiduria in non-neutropenic Treatment of asymptomatic candiduria in non-neutropenic catheterized patients has catheterized patients has nevernever been shown to be of value. been shown to be of value.

No diagnostic criteria for urinary candidiasisNo diagnostic criteria for urinary candidiasis

Candiduria in neutropenic patients, critically ill patients in ICUs, infants Candiduria in neutropenic patients, critically ill patients in ICUs, infants with low birth weight, and recipients of a transplant may be an with low birth weight, and recipients of a transplant may be an indicator of disseminated candidiasis.indicator of disseminated candidiasis.

Treatment of persistently febrile patients who have candiduria but Treatment of persistently febrile patients who have candiduria but who lack evidence for infection at other sites may treat occult who lack evidence for infection at other sites may treat occult disseminated candidiasis.disseminated candidiasis.

When treatment is indicated, systemic antifungal therapy should be When treatment is indicated, systemic antifungal therapy should be used.used.

Until better diagnostic techniques become available, the decision to Until better diagnostic techniques become available, the decision to initiate antifungal therapy remains mostly one of clinical judgment.initiate antifungal therapy remains mostly one of clinical judgment.

Documents

Candiduria: Should we treat, when and how? Hail M. Al-Abdely, MD Consultant Infectious Diseases King Faisal Specialist Hospital & Research Center