Fluconazole Dosing for Candiduria in Dialysis Patients

Candiduria Management Algorithm

The Infectious Diseases Society of America recommends that asymptomatic candiduria generally does not require treatment unless the patient belongs to a high-risk group, such as neutropenic patients, very low birth weight infants, or patients undergoing urologic manipulation 1, 2
Dialysis patients with candiduria should be evaluated for symptoms and risk of dissemination before initiating treatment, according to the Infectious Diseases Society of America 2
Removal of indwelling bladder catheters, if present, is strongly recommended as this alone may resolve candiduria in nearly half of cases, as suggested by the Infectious Diseases Society of America 1

For fluconazole-susceptible organisms, the recommended maintenance dose is 200 mg daily for 2 weeks, and for hemodialysis patients, the dose should be administered after each hemodialysis session, as recommended by the Infectious Diseases Society of America 1, 2
For fluconazole-resistant C. glabrata, treatment options include Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days or oral flucytosine 25 mg/kg 4 times daily for 7-10 days, according to the Infectious Diseases Society of America 1, 2
For C. krusei infections, treatment with Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days is recommended by the Infectious Diseases Society of America 1, 2

For pyelonephritis without dissemination, fluconazole 200-400 mg daily for 2 weeks for susceptible organisms is recommended by the Infectious Diseases Society of America 1, 3
For patients with fungal balls or obstructive uropathy, surgical intervention is strongly recommended by the Infectious Diseases Society of America 3, 4

Continuing indwelling catheters during treatment significantly reduces cure rates; removal of catheters is recommended whenever possible, as suggested by the Infectious Diseases Society of America 1, 2
Fluconazole resistance may develop during therapy, particularly with C. glabrata; monitoring of clinical response and consideration of follow-up cultures if improvement is not observed is recommended by the Infectious Diseases Society of America 1, 3

The American Journal of Kidney Diseases recommends reducing the maintenance dose of fluconazole by 50% when GFR is <45 mL/min/1.73 m², as the drug is primarily renally excreted unchanged (approximately 60% in 48 hours) 5
Reduce warfarin dose and monitor INR closely, particularly when GFR <30 mL/min/1.73 m², as there is increased bleeding risk and fluconazole potentiates warfarin's anticoagulant effect 5