Urinary Tract Infections

Introduction to Treatment

The Infectious Diseases Society of America recommends oral fluconazole 200 mg daily for 2 weeks as the first-line treatment for symptomatic Candida UTIs, along with removal of any indwelling bladder catheter if present 1
Treatment is NOT recommended for asymptomatic candiduria unless the patient belongs to a high-risk group, such as neutropenic patients, very low birth weight infants, patients undergoing urologic manipulation, or patients with suspected disseminated infection 1

High-risk groups, including neutropenic patients, very low birth weight infants (<1500g), patients undergoing urologic manipulation, and patients with suspected disseminated infection, require treatment regardless of symptoms 1
The European Society of Clinical Microbiology and Infectious Diseases notes that asymptomatic funguria generally does not require treatment, but funguria resolves without treatment in approximately 76% of cases 2

Removing indwelling bladder catheters whenever possible can resolve candiduria in approximately 50% of cases, as strongly recommended by the Infectious Diseases Society of America 1
Eliminate urinary tract obstruction if present, as strongly recommended by the Infectious Diseases Society of America 1
Remove or replace nephrostomy tubes/stents if present, as recommended by the Infectious Diseases Society of America 1

Oral fluconazole 200 mg daily for 2 weeks is the recommended first-line treatment for symptomatic Candida UTIs, as recommended by the Infectious Diseases Society of America 1
Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days is an alternative first-line treatment 1

The following treatment options are recommended by the Infectious Diseases Society of America:

Fungal Species	Treatment Option	Dosage
Fluconazole-susceptible	Fluconazole	200 mg loading dose, 200 mg after each dialysis for cystitis, 200-400 mg after each dialysis for pyelonephritis
Fluconazole-resistant	Amphotericin B deoxycholate	0.3-0.6 mg/kg daily for 1-7 days
Fluconazole-resistant	Flucytosine	25 mg/kg 4 times daily for 7-10 days

Oral flucytosine 25 mg/kg 4 times daily for 7-10 days can be considered as an alternative treatment 1
Combination therapy with both fluconazole and amphotericin B deoxycholate can be considered for severe infections 1
Local irrigation with amphotericin B at 50 mg/L of sterile water may be considered as an adjunct to systemic therapy 4
Irrigation through nephrostomy tubes with amphotericin B deoxycholate if present, as recommended by the Infectious Diseases Society of America 1

The standard treatment duration is 2 weeks for uncomplicated infections, or until symptoms resolve and urine cultures become negative, with follow-up urine cultures obtained to confirm eradication 1
Clinical improvement of symptoms should be assessed, and treatment should continue until symptoms resolve and urine cultures become negative 1, 4

For complicated UTI or pyelonephritis, oral options include Ciprofloxacin 500-750 mg twice daily for 7 days or levofloxacin 750 mg daily for 5 days, as recommended by the European Urology guidelines 5
If hospitalization is required for complicated UTI or pyelonephritis, intravenous options should be considered, according to the European Urology guidelines 5
Fungal infections in obstructive uropathy require prompt management to prevent further complications, as recommended by the World Society of Emergency Surgery and the Best Practice Statement on Urologic Procedures 6, 7
Antifungal therapy is recommended for patients with significant risk factors for candidiasis, particularly in high-risk scenarios such as obstructive uropathy, as stated by the World Society of Emergency Surgery guidelines and the Best Practice Statement on Urologic Procedures 6, 7

Obtain urine culture to identify causative organism and susceptibility, as recommended by the Infectious Diseases Society of America, to guide treatment decisions 3
Complete a metabolic panel to assess renal function, electrolytes, and glucose levels, and order blood cultures to rule out fungemia, especially if fever is present, as candidemia is associated with high mortality and would require more aggressive treatment 1
Daily assessment of mental status, monitoring for potential drug interactions, and monitoring renal function, especially in elderly patients with multiple medications 1

Treating asymptomatic candiduria in low-risk patients is unnecessary and may promote resistance 1
Failing to remove indwelling catheters can lead to persistent infection 1
Not considering species-specific resistance patterns, particularly for C. glabrata and C. krusei, can lead to inadequate treatment 1
Inadequate treatment duration, less than 2 weeks for symptomatic infections, can lead to treatment failure 1