Re: Fluconazole treatment in Torulopsis glabrata upper urinary tract infection causing ureteral obstruction

Candida urinary tract infection and Candida species susceptibilities to antifungal agents

The purpose of this study is to review Candida isolation from urine of urinary tract infection (UTI) patients over the recent 3 years at the Kobe University Hospital. We recorded the type of strain, the department where the patient was treated such as the intensive care unit (ICU), and combined isolation of Candida with other microorganisms. We investigated Candida isolation and susceptibilities to antifungal agents and analyzed the risk factors for combined isolation with other microorganisms. The most frequently isolated Candida was Candida albicans, which showed good (100%) susceptibilities to 5-fluorocytosine (5-FC) and fluconazole (FLCZ) but not to voriconazole (VRCZ), followed by C. glabrata. ICU was the greatest source of Candida-positive samples, and the most relevant underlying diseases of ICU patients were pneumonia followed by renal failure and post liver transplantation status. Combined isolation with other bacteria was seen in 27 cases (42.9%) in 2009, 25 (33.3%) in 2010 and 31 (31.3%) in 2011 and comparatively often seen in non-ICU patients. Other candidas than C. albicans showed significantly decreased susceptibility to FLCZ over these 3 years (P=0.004). One hundred (97.1%) of 103 ICU cases were given antibiotics at the time of Candida isolation, and the most often used antibiotics were cefazolin or meropenem. In conclusion, C. albicans was representatively isolated in Candida UTI and showed good susceptibilities to 5-FC, FLCZ and VRCZ, but other candidas than C. albicans showed significantly decreased susceptibility to FLCZ in the change of these 3 years.

Candida urinary tract infections--treatment

In many instances a report from the clinical laboratory indicating candiduria represents colonization or procurement contamination of the specimen and not invasive candidiasis. Even if infection of the urinary tract by Candida species can be confirmed, antifungal therapy is not always warranted. Further investigation may reveal predisposing factors, which if corrected or treated, result in the resolution of the infection. For those with symptomatic urinary tract infections (UTIs), the choice of antifungal agent will depend upon the clinical status of the patient, the site of infection, and the pharmacokinetics and pharmacodynamics of the agent. Because of its safety, achievement of high concentrations in the urine, and availability in both an oral and intravenous formulation, fluconazole is preferred for the treatment of Candida UTIs. Flucytosine is concentrated in urine and has broad activity against Candida spp, but its use requires caution because of toxicity. Low-dose amphotericin B may be useful for Candida UTIs in selected patients. The role of echinocandins and azoles that do not achieve measurable concentrations in the urine is not clear. Small case series note some success, but failures have also occurred. Irrigation of the bladder with antifungal agents has limited utility. However, with fungus balls, irrigation of the renal pelvis through a nephrostomy tube can be useful in combination with systemic antifungal agents.

Antifungal therapy--state of the art at the beginning of the 21st century

The most relevant information on the present state of the art of antifungal chemotherapy is reviewed in this chapter. For dermatomycoses a variety of topical antifungals are available, and safe and efficacious systemic treatment, especially with the fungicidal drug terbinafine, is possible. The duration of treatment can be drastically reduced. Substantial progress in the armamentarium of drugs for invasive fungal infections has been made, and a new class of antifungals, echinocandins, is now in clinical use. The following drugs in oral and/or intravenous formulations are available: the broad spectrum polyene amphotericin B with its new "clothes"; the sterol biosynthesis inhibitors fluconazole, itraconazole, and voriconazole; the glucan synthase inhibitor caspofungin; and the combination partner flucytosine. New therapy schedules have been studied; combination therapy has found a significant place in the treatment of severely compromised patients, and the field of prevention and empiric therapy is fast moving. Guidelines exist nowadays for the treatment of various fungal diseases and maintenance therapy. New approaches interfering with host defenses or pathogenicity of fungal cells are being investigated, and molecular biologists are looking for new targets studying the genomics of pathogenic fungi.

Fungal infections of the genitourinary system: manifestations, diagnosis, and treatment

There is an increasing pool of immunocompromised patients who are at an increased risk to fungi infections, which now cause 8% of nosocomial infections. Premature infants and elderly, transplant, and HIV patients are prime candidates for invasive fungal infections. The genitourinary system can be a source or target of disseminated fungal infection. Although candidal species are the most frequent pathogen, other species such as aspergila, cryptoccoccus have become major pathogens. "Environmental fungi," which include blastomyces, coccidioides and histoplasma, have become more aggressive in the vulnerable patient.