Candiduria: To treat or not to treat?

Dear Editor, In present times, with increase in the number of people using urinary catheters and antibiotics, finding Candida in urine has become increasingly common, but knowing when to treat it, is still a confusing and important issue for clinicians. To begin with, cadiduria refers to the presence of Candida species in the urine. The most frequent species isolated is Candida albicans followed by non-albicans Candida such as C. glabrata, C. tropicalis, and C. krusei. Recent epidemiological trends suggest a paradigm shift toward the predominance of non-albicans Candida species that often display reduced susceptibility to azoles.[1–3] However, the everlasting question remains “Should candiduria be treated?” The answer is simple yet debatable. The critical step is distinguishing colonization from infection. Colonization can occur due to contamination during sample collection or asymptomatic colonization of the urinary tract whereas, true infection is associated with host response. To distinguish the two scenarios is often a major challenge for the clinicians. Asymptomatic candiduria is usually benign and does not require treatment in the absence of high-risk conditions. In contrast, symptomatic candiduria often presents with signs of urinary tract infection (UTI) and significant particularly in immunocompromised individuals or those with underlying urological abnormalities. Additionally, candidemia may occasionally originate from a urinary source, especially in high-risk individuals.[3,4] The diagnostic modalities rely mainly on urine culture and its role cannot be undermined. Microscopy and quantitative culture help assess fungal load, while repeat cultures and clinical correlation remain essential for an accurate diagnosis and treatment. A single positive culture cannot be considered definitive. In selected cases, blood culture, imaging, or ultrasound may be required to exclude systemic involvement or obstructive pathology. So, when should candiduria be treated? The decision must be individualized. According to the Infectious Diseases Society of America (IDSA) guidelines, treatment is recommended in the scenarios such as symptomatic UTI, neutropenia, low birth weight neonates, and patients undergoing urologic procedures.[4,5] In patients with indwelling catheters and asymptomatic candiduria, removal of catheter often suffices. Fluconazole remains the drug of choice due to its urinary excretion, though resistance in non albicans species necessitates alternative agents such as amphotericin B or echinocandins.[1,5] For example, Deng et al.[6] described a patient with asymptomatic candiduria caused by Candida glabrata. Despite repeated positive urine cultures, the patient exhibited no clinical symptoms, and invasive disease was excluded. Management without systemic antifungal therapy, combined with careful clinical monitoring, led to resolution. This case highlights the importance of distinguishing colonization from true infection and supports the principle of avoiding unnecessary antifungal treatment when candiduria is incidental. In summary, the management of candiduria requires careful clinical judgement that integrates microbiological results, patient risk factors, and symptomatology. Overuse of antifungals in colonized patients increases costs and resistant pressure, especially among non-albicans Candida species. The guiding principle remains “treat the patient, not the culture.” Future research should focus on the rapid diagnostic tools and local resistance surveillance to refine treatment strategies and optimize patient outcomes. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.