What Is the Appropriate Evaluation and Treatment of Funguria?

However, for certain patient populations who are at increased risk for developing a disseminated fungal infection, the treatment of asymptomatic funguria is indicated. This includes neutropenic patients, those with a known urologic obstruction, and those who will undergo a urologic procedure.7 It also is important to recognize that for oncology patients, or those with sepsis, funguria might be the only manifestation of a disseminated fungal infection.6

All patients with symptomatic funguria require treatment with antifungal therapy.6 Septic patients who have funguria require blood cultures and radiologic imaging studies; the latter are obtained in order to localize the anatomic source of infection, and also to evaluate for urinary obstruction.6 Such patients require the prompt administration of appropriate systemic antifungal therapy; failure to do so doubles the risk of in-hospital mortality.2

Fluconazole is the most utilized medication for funguria treatment. Unlike itraconazole, ketoconazole, and voriconazole, it achieves high concentrations in the urine.7,12 The efficacy of Capsofungin for the treatment of funguria has not been established firmly.14,17 Flucytosine has a limited role in the treatment of funguria, but it is very useful in the treatment of non-C. albicans species, which are increasing in frequency and often are resistant to fluconazole.6,14

Amphotericin B bladder irrigation no longer is recognized as a first-line treatment for candiduria, although some investigators still support its use, particularly in special circumstances.15 With the ready availability of an oral agent, IV amphotericin B is not commonly utilized for the treatment of asymptomatic funguria. However, either IV amphotericin B or IV fluconazole are options for the treatment of renal candidiasis.3,7 Unfortunately, the recurrence of funguria after the completion of an appropriate course of antifungal therapy commonly occurs.3,6,8,14,15

Back to the Case

Common risk factors for funguria development include the use of urinary tract drainage devices, hyperalimentation, steroids, recent antibiotic therapy, diabetes mellitus, increased age, urinary tract abnormalities, female sex, malignancy, and a previous surgical procedure.

The patient’s initial blood and sputum cultures grew Streptococcus pneumoniae, which was adequately covered by the initial treatments of piperacillin/tazobactam and levofloxacin at the time of admission. Although the patient’s clinical condition improved gradually, she required ICU management throughout her hospital stay. Due to her poor mobility, an indwelling urinary catheter was inserted. The placement of this catheter, along with her age, sex, current antibiotic therapy, and debility, all increased her likelihood of developing funguria.

It is noteworthy that the patient had no suprapubic tenderness, and she had been afebrile for the preceeding 48 hours.

The finding of funguria in this patient should not create undue concern. The true source of her acute illness (Streptococcus pneumoniae) was identified. In this instance, there would be no expected benefit from the initiation of antifungal therapy. Instead, removal of the indwelling urinary drainage device would be advisable.

Bottom Line

Asymptomatic funguria is a common clinical finding, one in which further workups or the administration of antifungal therapy is not necessary in most cases. Symptomatic funguria always requires treatment. TH

Dr. Clarke is a clinical instructor in the section of hospital medicine at Emory University Medical Center in Atlanta. Dr. Razavi is an assistant professor in the section of hospital medicine at Emory.

References

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