Management of Candida Infections of the Urinary System

To provide a concise, practice-oriented synthesis on Candida urinary tract infections: epidemiology and clinical significance of candiduria; when candiduria reflects colonization vs. infection; pharmacology of key antifungals focused on urinary and renal tissue penetration; the roles of source control and urologic intervention; and management in special scenarios (pre-urologic procedures, obstruction, devices, and impaired renal function). Fluconazole remains first-line therapy for susceptible isolates given excellent urinary and renal penetration. Echinocandins and lipid amphotericin B achieve low urinary concentrations and may be unreliable for treatment of cystitis, whereas amphotericin B deoxycholate and flucytosine attain therapeutic urinary concentrations (with nephrotoxicity and hematologic toxicity considerations). Novel agents such as rezafungin, fosmanogepix, oteseconazole, ibrexafungerp and encochleated amphotericin B show promising PK/tissue distribution but there are limited data defining their potential role in treating lower-tract disease. Intravesical or nephrostomy instillation of amphotericin B can produce short-term clearance in resistant or device-associated infections, yet relapse is common without addressing obstruction or removing/exchanging hardware. Pre-procedural candiduria may increase postoperative complications in selected populations; short-course targeted therapy is reasonable before intermediate-/high-risk genitourinary interventions. Renal impairment requires dose adjustment for fluconazole and flucytosine, avoidance of cyclodextrin-containing IV azoles, and preference for lipid amphotericin when a polyene is needed. The work up of candiduria should prioritize confirming infection, prompt source control (catheter/device management, relief of obstruction), and organism-directed therapy. Treat selectively: many asymptomatic cases resolve with device measures alone; symptomatic or high-risk situations are best treated with fluconazole when active, or amphotericin B deoxycholate or flucytosine for resistant species. Reserve local instillation for carefully chosen cases. Coordinated ID–urology care and procedure-specific planning reduce relapse and complications; key gaps include standardized instillation regimens and trials defining who benefits from antifungal therapy and the role of novel antifungals.