Urogenit Tract Infect.  2019 Aug;14(2):33-41. 10.14777/uti.2019.14.2.33.

Management of Candida Urinary Tract Infection in the Elderly

• Kim SJ
• Ryu JH
• Kim YB
• Yang SO

• KMID: 2456607
• DOI: http://doi.org/10.14777/uti.2019.14.2.33

Abstract

Candida urinary tract infections in elderly patients are becoming increasingly common. The risk factors for the development of candiduria include old age, use of broad-spectrum antibiotics, corticosteroids and indwelling urethral catheters, as well as diabetes mellitus, urological abnormalities, and hematological malignancies. The presence of signs and symptoms of infection are unusual, and the intensity of fungal growth in culture does not correlate with the outcome. Elderly patients often present with atypical signs and symptoms of infection. Careful assessment of the patient's clinical status should be undertaken before treatment is initiated. The indications for antifungal therapy are the same for older and younger individuals, and the initial antifungal therapy should be selected based on the infecting organism and local epidemiology. Fluconazole is the mainstay of treatment. On the other hand, Candida glabrata is more common in elderly patients and is often refractory to fluconazole therapy. The selection of drug therapy for elderly patients should consider the comorbidities, risk of drug-drug interactions, and dose adjustment for physiological function.

Keyword

Candida; Disease management; Frail elderly; Urinary tract infections

MeSH Terms

Adrenal Cortex Hormones
Aged*
Anti-Bacterial Agents
Candida glabrata
Candida*
Comorbidity
Diabetes Mellitus
Disease Management
Drug Therapy
Epidemiology
Fluconazole
Frail Elderly
Hand
Hematologic Neoplasms
Humans
Risk Factors
Urinary Catheters
Urinary Tract Infections*
Urinary Tract*
Adrenal Cortex Hormones
Anti-Bacterial Agents
Fluconazole

Reference

1. Rivett AG, Perry JA, Cohen J. Urinary candidiasis: a prospective study in hospital patients. Urol Res. 1986; 14:183–186.

2. Hamory BH, Wenzel RP. Hospital-associated candiduria: predisposing factors and review of the literature. J Urol. 1978; 120:444–448.

3. Kauffman CA, Vazquez JA, Sobel JD, Gallis HA, McKinsey DS, Karchmer AW, et al. Prospective multicenter surveillance study of funguria in hospitalized patients. Clin Infect Dis. 2000; 30:14–18.

4. Ayeni O, Riederer KM, Wilson FM, Khatib R. Clinicians' reaction to positive urine culture for Candida organisms. Mycoses. 1999; 42:285–289.

5. Storfer SP, Medoff G, Fraser VJ, Powderly WG, Dunagan WC. Candiduria: retrospective review in hospitalized patients. Infect Dis Clin Pract. 1994; 3:23–29.

6. Harris AD, Castro J, Sheppard DC, Carmeli Y, Samore MH. Risk factors for nosocomial candiduria due to Candida glabrata and Candida albicans. Clin Infect Dis. 1999; 29:926–928.

7. Jacobs LG. Fungal urinary tract infections in the elderly: treatment guidelines. Drugs Aging. 1996; 8:89–96.

8. Kauffman CA. Fungal infections in older adults. Clin Infect Dis. 2001; 33:550–555.

9. Pfaller MA, Diekema DJ. Epidemiology of invasive candidiasis: a persistent public health problem. Clin Microbiol Rev. 2007; 20:133–163.

10. Dimopoulos G, Paiva JA, Meersseman W, Pachl J, Grigoras I, Sganga G, et al. Efficacy and safety of anidulafungin in elderly, critically ill patients with invasive Candida infections: a post hoc analysis. Int J Antimicrob Agents. 2012; 40:521–526.

11. Flevari A, Theodorakopoulou M, Velegraki A, Armaganidis A, Dimopoulos G. Treatment of invasive candidiasis in the elderly: a review. Clin Interv Aging. 2013; 8:1199–1208.

12. Bouza E, San Juan R, Munoz P, Voss A, Kluytmans J. Cooperative Group of the European Study Group on Nosocomial Infections. A European perspective on nosocomial urinary tract infections I. Report on the microbiology workload, etiology and antimicrobial susceptibility (ESGNI-003 study). European Study Group on Nosocomial Infections. Clin Microbiol Infect. 2001; 7:523–531.

13. Sobel JD, Fisher JF, Kauffman CA, Newman CA. Candida urinary tract infections--epidemiology. Clin Infect Dis. 2011; 52 Suppl 6:S433–S436.

14. Kobayashi CC, de Fernandes OF, Miranda KC, de Sousa ED, Silva Mdo R. Candiduria in hospital patients: a study prospective. Mycopathologia. 2004; 158:49–52.

15. Safdar N, Slattery WR, Knasinski V, Gangnon RE, Li Z, Pirsch JD, et al. Predictors and outcomes of candiduria in renal transplant recipients. Clin Infect Dis. 2005; 40:1413–1421.

16. Nguyen MH, Peacock JE Jr, Morris AJ, Tanner DC, Nguyen ML, Snydman DR, et al. The changing face of candidemia: emergence of non-Candida albicans species and antifungal resistance. Am J Med. 1996; 100:617–623.

17. Malani PN, Bradley SF, Little RS, Kauffman CA. Trends in species causing fungaemia in a tertiary care medical centre over 12 years. Mycoses. 2001; 44:446–449.

18. Pfaller MA, Diekema DJ. Role of sentinel surveillance of candidemia: trends in species distribution and antifungal susceptibility. J Clin Microbiol. 2002; 40:3551–3557.

19. Pfaller MA, Diekema DJ, Jones RN, Messer SA, Hollis RJ. SENTRY Participants Group. Trends in antifungal susceptibility of Candida spp. isolated from pediatric and adult patients with bloodstream infections: SENTRY Antimicrobial Surveillance Program, 1997 to 2000. J Clin Microbiol. 2002; 40:852–856.

20. Guinea J. Global trends in the distribution of Candida species causing candidemia. Clin Microbiol Infect. 2014; 20 Suppl 6:5–10.

21. Malani A, Hmoud J, Chiu L, Carver PL, Bielaczyc A, Kauffman CA. Candida glabrata fungemia: experience in a tertiary care center. Clin Infect Dis. 2005; 41:975–981.

22. Phillips JR, Karlowicz MG. Prevalence of Candida species in hospital-acquired urinary tract infections in a neonatal intensive care unit. Pediatr Infect Dis J. 1997; 16:190–194.

23. Kauffman CA. Diagnosis and management of fungal urinary tract infection. Infect Dis Clin North Am. 2014; 28:61–74.

24. Hof H, Mikus G. [Candida infections in the elderly]. Z Gerontol Geriatr. 2013; 46:64–70. German.

25. Aw D, Silva AB, Palmer DB. Is thymocyte development functional in the aged? Aging (Albany NY). 2009; 1:146–153.

26. Colonna-Romano G, Buffa S, Bulati M, Candore G, Lio D, Pellicanò M, et al. B cells compartment in centenarian offspring and old people. Curr Pharm Des. 2010; 16:604–608.

27. Deray G. Amphotericin B nephrotoxicity. J Antimicrob Chemother. 2002; 49 Suppl 1:37–41.

28. Stine JG, Sateesh P, Lewis JH. Drug-induced liver injury in the elderly. Curr Gastroenterol Rep. 2013; 15:299.

29. Woodhouse K, Wynne HA. Age-related changes in hepatic function. Implications for drug therapy. Drugs Aging. 1992; 2:243–255.

30. Tulner LR, Kuper IM, Frankfort SV, van Campen JP, Koks CH, Brandjes DP, et al. Discrepancies in reported drug use in geriatric outpatients: relevance to adverse events and drugdrug interactions. Am J Geriatr Pharmacother. 2009; 7:93–104.

31. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003; 163:2716–2724.

32. Gallagher P, Barry P, O'Mahony D. Inappropriate prescribing in the elderly. J Clin Pharm Ther. 2007; 32:113–121.

33. Wey SB, Mori M, Pfaller MA, Woolson RF, Wenzel RP. Risk factors for hospital-acquired candidemia. A matched case-control study. Arch Intern Med. 1989; 149:2349–2353.

34. Fisher JF, Kavanagh K, Sobel JD, Kauffman CA, Newman CA. Candida urinary tract infection: pathogenesis. Clin Infect Dis. 2011; 52 Suppl 6:S437–S451.

35. MacCallum DM, Odds FC. Temporal events in the intravenous challenge model for experimental Candida albicans infections in female mice. Mycoses. 2005; 48:151–161.

36. Kauffman CA. Candiduria. Clin Infect Dis. 2005; 41 Suppl 6:S371–S376.

37. Achkar JM, Fries BC. Candida infections of the genitourinary tract. Clin Microbiol Rev. 2010; 23:253–273.

38. Siddique MS, Gayed N, McGuire N, Khatilb R. Salient features of Candida pyelonephritis in adults. Infect Dis Clin Pract. 1992; 1:240–245.

39. Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients. Arch Intern Med. 2000; 160:678–682.

40. You JH, Kim MK. Bacterial urosepsis by a fungal ball mimicking a ureteral stone. Korean J Urogenit Tract Infect Inflamm. 2014; 9:115–118.

41. Jacobs LG, Skidmore EA, Cardoso LA, Ziv F. Bladder irrigation with amphotericin B for treatment of fungal urinary tract infections. Clin Infect Dis. 1994; 18:313–318.

42. Fisher JF, Newman CL, Sobel JD. Yeast in the urine: solutions for a budding problem. Clin Infect Dis. 1995; 20:183–189.

43. Bougnoux ME, Kac G, Aegerter P, d'Enfert C, Fagon JY. CandiRea Study Group. Candidemia and candiduria in critically ill patients admitted to intensive care units in France: incidence, molecular diversity, management and outcome. Intensive Care Med. 2008; 34:292–299.

44. Drogari-Apiranthitou M, Anyfantis I, Galani I, Kanioura L, Daikos GL, Petrikkos G. Association between candiduria and candidemia: a clinical and molecular analysis of cases. Mycopathologia. 2017; 182:1045–1052.

45. Sobel JD, Kauffman CA, McKinsey D, Zervos M, Vazquez JA, Karchmer AW, et al. Candiduria: a randomized, double-blind study of treatment with fluconazole and placebo. Clin Infect Dis. 2000; 30:19–24.

46. Ang BS, Telenti A, King B, Steckelberg JM, Wilson WR. Candidemia from a urinary tract source: microbiological aspects and clinical significance. Clin Infect Dis. 1993; 17:662–666.

47. Gross M, Winkler H, Pitlik S, Weinberger M. Unexpected candidemia complicating ureteroscopy and urinary stenting. Eur J Clin Microbiol Infect Dis. 1998; 17:583–586.

48. Pappas PG, Kauffman CA, Andes D, Benjamin DK Jr, Calandra TF, Edwards JE Jr, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009; 48:503–535.

49. Yang SO. Catheter-associated urinary tract infection. Korean J Urogenit Tract Infect Inflamm. 2013; 8:73–82.

50. Auger P, Dumas C, Joly J. A study of 666 strains of Candida albicans: correlation between serotype and susceptibility to 5-fluorocytosine. J Infect Dis. 1979; 139:590–594.

51. Fisher JF, Sobel JD, Kauffman CA, Newman CA. Candida urinary tract infections--treatment. Clin Infect Dis. 2011; 52 Suppl 6:S457–S466.

52. Goldman HJ, Littman ML, Oppenheimer GD, Glickman SI. Monilial cystitis-effective treatment with instilations of amphotericin B. JAMA. 1960; 174:359–362.

53. Drew RH, Arthur RR, Perfect JR. Is it time to abandon the use of amphotericin B bladder irrigation? Clin Infect Dis. 2005; 40:1465–1470.

54. Agustin J, Lacson S, Raffalli J, Aguero-Rosenfeld ME, Wormser GP. Failure of a lipid amphotericin B preparation to eradicate candiduria: preliminary findings based on three cases. Clin Infect Dis. 1999; 29:686–687.

55. Wise GJ, Shteynshlyuger A. How to diagnose and treat fungal infections in chronic prostatitis. Curr Urol Rep. 2006; 7:320–328.

56. Bartkowski DP, Lanesky JR. Emphysematous prostatitis and cystitis secondary to Candida albicans. J Urol. 1988; 139:1063–1065.

57. Giannopoulos A, Giamarellos-Bourboulis EJ, Adamakis I, Georgopoulou I, Petrikkos G, Katsilambros N. Epididymitis caused by Candida glabrata: a novel infection in diabetic patients? Diabetes Care. 2001; 24:2003–2004.

58. Jenkin GA, Choo M, Hosking P, Johnson PD. Candidal epididymoorchitis: case report and review. Clin Infect Dis. 1998; 26:942–945.

59. Fisher J, Mayhall G, Duma R, Shadomy S, Shadomy J, Watlington C. Fungus balls of the urinary tract. South Med J. 1979; 72:1281–1284. 1287

60. Chung BH, Chang SY, Kim SI, Choi HS. Successfully treated renal fungal ball with continuous irrigation of fluconazole. J Urol. 2001; 166:1835–1836.

61. Bartone FF, Hurwitz RS, Rojas EL, Steinberg E, Franceschini R. The role of percutaneous nephrostomy in the management of obstructing candidiasis of the urinary tract in infants. J Urol. 1988; 140:338–341.

62. Chitale SV, Shaida N, Burtt G, Burgess N. Endoscopic management of renal candidiasis. J Endourol. 2004; 18:865–866.

63. Kabaalioğlu A, Bahat E, Boneval C. Renal candidiasis in a 2-month-old infant: treatment of fungus balls with streptokinase. AJR Am J Roentgenol. 2001; 176:511–512.

64. Fisher JF, Woeltje K, Espinel-Ingroff A, Stanfield J, DiPiro JT. Efficacy of a single intravenous dose of amphotericin B for Candida urinary tract infections: further favorable experience. Clin Microbiol Infect. 2003; 9:1024–1027.