What Is the Appropriate Evaluation and Treatment of Funguria?

Case

A previously healthy 74-year-old female was admitted to the ICU nine days ago for treatment of severe streptococcal pneumonia. Her initial urine culture, which was collected on hospital day one, showed no growth; however, Candida albicans was isolated from a urine culture collected seven days later. Her second urinalysis revealed mild pyuria. What is the appropriate evaluation and treatment of funguria?

Background

Candida albicans yeast.

PETER ARNOLD, INC./ALAMY
Candida albicans yeast.

Funguria is a relatively common clinical finding, and it is considerably more prevalent in patients with severe illnesses compared with healthy individuals. One study found that 2.2% of healthy, community-dwelling patients have Candida species (spp) in their urine.1 Candida spp are opportunistic organisms, which is implied by the fact that they can be isolated from 22% of patients admitted to an ICU.2

Despite the frequent isolation of Candida spp from urine cultures, the clinical significance is often unclear. It is difficult to determine if the funguria is caused by contamination, colonization, or a true urinary tract infection (UTI)—there is no test to reliably differentiate between these three possibilities. This is in contrast to bacterial UTIs, in which the findings of pyuria, bacteriuria, and a defined number of colony-forming units strongly support this diagnosis.3

Since it often is difficult to determine the true importance of funguria, its treatment has been controversial.3 The presence of a chronically indwelling urinary catheter often results in the funguria development, and, in many instances, simply removing the catheter will lead to its resolution.4 Furthermore, it has been demonstrated that for most patients with asymptomatic funguria, treatment with antifungal therapy has no effect on morbidity or mortality.5,6 Also, the propensity for funguria recurrence after completion of a course of antifungal therapy often discourages clinicians from ordering pharmacologic therapy.7,8

Review of the Data

KEY Points

  • Asymptomatic funguria is commonly diagnosed, usually in debilitated patients, and most frequently has a benign prognosis, thus negating the need for antifungal therapy.
  • Treatment of asymptomatic funguria is indicated for certain patient populations, particularly those at risk for developing a disseminated fungal infection.
  • Symptomatic funguria should be treated with appropriate antifungal therapy.

Additional Reading

  • Kauffman, CA. Candiduria. Clin Infect Dis. 2005;41:S371-376.
  • Lundstrom T, Sobel J. Nosocomial candiduria: a review. Clin Infect Dis. 2001;32:1602-1607.
  • Kauffman CA, Vazquez JA, Sobel JD, et al. Prospective multicenter surveillance study of funguria in hospitalized patients. Clin Infect Dis. 2000;30:14-18.
  • Hollenbach E. To treat or not to treat—critically ill patients with candiduria. Mycoses. 2008;51(Suppl2):12-24.
  • Bukhary ZA. Candiduria: a review of clinical significance and management. Saudi J Kidney Dis Transplant. 2008;19(3):350-360.

The prevalence of funguria is increasing worldwide, primarily due to the increased use of antibiotics and immunosuppressive therapy, as well as the more frequent utilization of invasive procedures.1,7 Candida spp cause as many as 30% of all nosocomial UTIs, and they are most commonly isolated from patients who require ICU treatment.9 In fact, in one large study, only 10.9% of 861 patients with funguria had no underlying illnesses.10

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