Should we treat asymptomatic candiduria?

This is a common scenario among our hospitalized patients with indwelling catheters, prior antibiotic therapy or diabetes mellitus who seem to have no clinical signs of infection. Fortunately, candidemia from urinary sources appears uncommon to rare, with up to nearly ½ of patients clearing their candiduria with removal of the indwelling catheter alone (1). The Infectious Diseases Society of America guidelines do not recommended treatment of asymptomatic candiduria unless the patient belongs to a group at high risk of dissemination, such as severely immunosuppressed or neutropenic patients, infants with low birth weight, and patients who will undergo urologic manipulation (2).  Supporting such recommendation is a retrospective long-term follow-up of patients with candiduria demonstrating no significant improvement in rates of recurrences of candiduria or candidemia with treatment (3).  Fluconazole is usually considered the first-line agent of choice when treatment is indicated.  

1. Kauffman CA. Candiduria. Clin Infect Dis 2005;41:S371-6.

2. Pappas PG, Kauffman CA, Andes D, et al. Clinical Practice Guidelines for the Management of Candidiasis: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 48:503–35.

3. Revankar SG, Hasan MS, Revankar VS, et al. Long-term follow-up of patients with candiduria. Eur J Clin Microbiol Infect Dis 2011;30:137-140.

Should we treat asymptomatic candiduria?

How do I interpret heavy growth of Candida sp. from sputum of my patient with COPD and pneumonia?

Chances are our patient has been on antibiotics and is being treated with either inhaled and/or systemic corticosteroids which may all contribute to yeast overgrowth in the respiratory and GI tracts.   Fortunately, in the absence of severe immunocompromised state such as neutropenia,  Candida sp. in  respiratory specimens (including those obtained by bronchoscopy) is only rarely associated with pneumonia (1,2).   So no antifungal therapy seems to be indicated in our patient, unless oral candidiasis (e.g. either thrush or the atrophic variety) is also simultaneously present.  Time to examine the mouth!

1. El-Ebiary M, Torres A, Fabregas N, et al. Significance of the isolation of Candida species from respiratory samples in critically ill, non-neutropenic  patients.  Am J Resp Crit Care Med 1997;156:583-590

2. Rello J, Wsandi ME, Diaz E, et al. The role of Candida sp. isolated from bronchoscopic samples in non-neutropenic patients. Chest 1998;114:146-49

How do I interpret heavy growth of Candida sp. from sputum of my patient with COPD and pneumonia?

Can oral candidiasis be symptomatic without actual pseudomembranes or “thrush”?

Yes.  A common form of oral candidiasis I see in hospitalized patients is of the “Erythematous (atrophic)” variety (1) which presents with dry mouth, sensitivity to food (especially carbonated drinks) and red patches on the palate and the tongue.  Patients often complain of their taste buds being “off” .  I have a low threshold for treating these patients empirically, often with oral nystatin or miconazole, as they improve rapidly with therapy.

1. Stoopler ET, Sollecito TP. Oral mucosal diseases. Med Clin N Am 2014;98:1323-1352. 

Can oral candidiasis be symptomatic without actual pseudomembranes or “thrush”?