Risk factors
- Diabetes
- Immunosuppression
- Antibiotics
- Hospitalisation and ICU
- Foreign bodies/indwelling plastic – catheters, stents
- Consider contamination from balanitis or vulvovaginitis
- Abnormal urinary tract or urinary obstruction
- Elderly
Organisms
- Usually candida albicans most common
- Second most common is candida glabrata – doesn’t usually respond to fluconazole
Clinical features
Often asymptomatic or colonisation
- Does not need treatment specifically if asymptomatic
- Change catheter
- Optimise health and nutrition
- Stop antibiotics if able
- Repeat culture after changing plastic
- Consider looking for nidus/fungal ball if persistent, or at risk of complications
If symptomatic of lower or upper tract UTI:
- Treat with anti-fungal
- Imaging to look for nidus or source
- Relieve any obstruction
Fungal balls:
- Generally require surgical removal (endoscopic vs percutaneous) under anti-fungal cover or infection will persist
- Upper urinary tract irrigation with amphotericin described via ureteric catheters or nephrostomies, also via catheter to irrigate bladder
- Speciation important for directing treatment
Disseminated candida / systemic candida / fungaemia:
- High mortality rate approaching 50 %, patients usually unwell
- ICU and ID involvement
- Often in immunosuppressed but also often gut/bowel source or from PICC/TPN etc
Treating pre-operatively?
AUA 2019 best practice statement on antibiotic prophylaxis:
Antifungal prophylaxis should be given to patients with asymptomatic funguria undergoing intermediate or high risk procedures – including … outlet procedures, TURBT, ureteroscopy, PCNL, all endoscopic procedures, using high pressure irrigants …
Antifungal treatment rather than single dose prophylaxis is recommended for symptomatic fungal UTIs prior to exchange of stents/tubes
In the absence of neutropenia or high risk features, asymptomatic funguria may not need prophylaxis for stent/tube change
Treatment of fungal balls – require speciation with sensitivities, antifungal treatment peri-operatively and continued treatment post-operatively (majority opinion 5 – 7 days)
Anti-fungal treatment
Fluconazole:
- 200 mg / day oral, higher doses intravenously for systemic disease
- Multiple drug interactions (CYP450)
- Liver dysfunction and QT prolongation
- Candida krusei inherently resistant
Other options include amphotericin or caspofungin for systemic disease.