Community-acquired and hospital-acquired candiduria: comparison of prevalence and clinical characteristics

Five-year cross-sectional study to determine the burden of Candida spp. infections of the urinary tract system among patients attending tertiary hospital in Northwestern Tanzania

OBJECTIVE

Urinary tract infections (UTIs) stand as a prominent global health concern. This study entails a 5-year retrospective analysis, using a cross-sectional study design to examine microbiology laboratory data of individuals clinically diagnosed with UTIs at Bugando Medical Centre to gain insights into the prevalence and factors linked to candiduria.

METHODOLOGY

Data extracted were meticulously cleaned and coded in an MS Excel sheet, subsequently transferred to STATA V.15 for analysis. Binary logistic regression analysis was used to identify factors associated with candiduria. A probability value below 0.05 at a 95% CI was considered statistically significant.

RESULTS

Urine samples for culture and sensitivity comprised 33.4% (20755) of the total biological samples (62335). The median age of the patients stood at 19 years. A slight majority were female, accounting for 52.8% (10051), and two-thirds sought treatment at outpatient departments (67.5%, 12843). Among patients with significant pathogenic growth, the prevalence of candiduria was 4.6% (221 out of 4772). Notably, inpatients exhibited a higher incidence of candiduria compared with outpatients, with rates of 9.4% (1882) versus 1.6% (2890), p value of 0.000. Non-albicans Candida spp. (NAC) remained the most prevalent pathogen. Factors significantly associated with candiduria included being female (OR=1.7, 95% CI 1.3 to 2.3) and hospital admission (OR=6.6, 95% CI 4.7 to 9.2). In conclusion, candiduria affect 5 out of every 100 UTI-diagnosed patients, predominantly among females and those admitted to the hospital. Clinicians at tertiary hospitals should consider urinary candidiasis as a potential diagnosis for patients at risk who present with UTI-like symptoms.

Intravesical Mycetoma misdiagnosed as enterovesical fistula

Fungus formation in the urinary tract mainly occurs in immunosuppressed patients, and is a rare and dangerous complication of candiduria that is commonly misdiagnosed. We report a case of intravesical mycetoma associated with hydronephrosis, initially diagnosed as enterovesical fistula. Cystoscopy revealed spongy material within the urinary bladder, and histopathological examination showed Mycetoma of Candida species. The urine culture showed Candida tropicalis. Endoscopic removal and antifungal therapy with fluconazole was initiated, and no complications occurred during follow-up.

Uncommon Haemorrhagic Cystitis of Infectious Origin: A Narrative Review for Urologists

Purpose

Haemorrhagic cystitis may be due to different etiologies with infectious diseases representing an insidious cause to diagnose. The aim of this narrative review is to provide a comprehensive overview of less common but difficult-to-diagnose causes of infectious haemorrhagic cystitis of bacterial, mycobacterial, and parasitic origin, Moreover, we highlight possible diagnostic tools and currently available treatment options in order to give an updated tool for urologists to use in daily practice.

Patients and Methods

The search engine PubMed was used to select peer-reviewed articles published from 1/Jan/2010 to 31/Aug/2022.

Results

Bacteria, fungal, TB and schistosomiasis are uncommon causes of haemorrhagic cystitis burdened by high morbidity, especially if not promptly diagnosed.

Conclusion

Because haemorrhagic cystitis ranges in severity from mild dysuria associated with pelvic discomfort to severe life-threatening haemorrhage, punctual diagnosis, and immediate treatment are essential to avoid further complications.

High prevalence of asymptomatic nosocomial candiduria due to Candida glabrata among hospitalized patients with heart failure: a matter of some concern?

Background and Purpose:

Heart failure is a leading cause of hospitalization, and asymptomatic candiduria is common in hospitalized patients with low morbidity. However, in most patients, it is resolved spontaneously on the removal of the catheter. Despite the publication of guidelines, there are still controversies over the diagnosis and management of candiduria. However, in hospitalized patients with heart failure, the decision to treat candiduria is especially important since the nosocomial infections are associated with an increase in morbidity, mortality, length of hospital stay, and healthcare costs. Some species of Candida, such as Candida glabrata, are increasingly resistant to the first-line and second-line antifungal medications. The present study aimed to investigate the incidence of asymptomatic Candida urinary tract infection due to C. glabrata and antifungal susceptibility of Candida isolates in hospitalized patients with heart failure.

Materials and Methods:

In total, 305 hospitalized patients with heart failure were studied to identify asymptomatic nosocomial candiduria during 2016-17 in one private hospital in the north of Iran. The Sabouraud’s dextrose agar culture plates with a colony count of >10⁴ colony-forming unit/ml of urine sample were considered as Candida urinary tract infection. Candida species were identified based on the morphology of CHROMagar Candida (manufactured by CHROMagar, France) and PCR-RFLP method with MspI restriction enzyme. Antifungal susceptibility testing of the isolates was performed using five mediations, including itraconazole, voriconazole, fluconazole, amphotericin B, and caspofungin by broth microdilution method according to CLSI M27-S4.

Results:

In this study, the rate of asymptomatic Candida urinary tract infection was 18.8%, which was more common in people above 51 years old and females (70%). In addition to the urinary and intravascular catheter, the occurrence of candiduria in hospitalized patients had significant relationships with a history of surgical intervention, diastolic heart failure, and use of systemic antibiotics (P>0.05). Among Candida spp., non-albicans Candida species was the most common infectious agent (59.7%). Moreover, C. glabrata (n=27, 40.3%) (alone or with other species) and Candida albicans (n=27, 40.3%) were the most common agents isolated in Candida urinary tract infection. Based on the results of the in vitro susceptibility test, the C. glabrata isolates were 15%, 59%, 70%, 74%, and 85% susceptible to caspofungin, amphotericin B, itraconazole, voriconazole, and fluconazole, respectively.

Conclusion:

According to the findings, there was a high prevalence of asymptomatic Candida urinary tract infection in hospitalized patients with heart failure. Besides, it was suggested that there was a shift towards non-albicans Candida, especially C. glabrata, in these patients. Therefore, asymptomatic candiduria in hospitalized patients with heart failure should be considered significant. Furthermore, the identification of Candida species along with antifungal susceptibility is essential and helps the clinicians to select the appropriate antifungal agent for better management of such cases.

Urine Sediment Findings and the Immune Response to Pathologies in Fungal Urinary Tract Infections Caused by Candida spp

Fungi are pathogenic agents that can also cause disseminated infections involving the kidneys. Besides Candida, other agents like Cryptococcus spp. can cause urinary tract infection (UTI), as well as other non-yeast fungi, especially among immunocompromised patients. The detection and identification of fungi in urine samples (by microscopy and culture) plays an essential role in the diagnosis of fungal UTI. However, variable cutoff definitions and unreliable culture techniques may skew analysis of the incidence and outcome of candiduria. The sediment analysis plays a key role in the identification of fungal UTI because both yeasts and pseudohyphae are easily identified and can be used as a clinical sign of fungal UTI but should not be overinterpreted. Indeed, urine markers of the immune response (leukocytes), urine barriers of tissue protection (epithelial cells), and urine markers of kidney disease (urinary casts) can be found in urine samples. This work explores the manifestations associated with the fungal UTI from the urinalysis perspective, namely the urinary findings and clinical picture of patients with fungal UTI caused by Candida spp., aspects associated with the immune response, and the future perspectives of urinalysis in the diagnosis of this clinical condition.

Candida urinary tract infections in adults

Candiduria is commonly seen in hospitalized patients and most of the patients are asymptomatic, but it may be due to cystitis, pyelonephritis, prostatitis, epididymo-orchitis or disseminated candidiasis. Major risk factors are diabetes mellitus, indwelling urinary catheters, use of broad-spectrum antibiotics, urinary obstruction, and admission to intensive care units. Candida urinary tract infections can be caused by hematogenous spread following candidemia, or retrograde route via the urethra. The presence of Candida species in urine in asymptomatic patients does not warrant antifungal therapy except neutropenic patients, very low-birth-weight infants and patients undergoing urologic procedures. Fluconazole is the treatment of choice for symptomatic infections, it achieves high urinary levels. The other azole antifungals and echinocandins do not reach sufficient urine levels. Amphotericin B deoxycholate is the alternative antifungal agent if fluconazole can not be used because of resistance, allergy or failure.

Candiduria in hospitalized patients: an investigation with the Sysmex UF-1000i urine analyzer

Background

Candiduria is common in hospitalized patients. Its management is limited because of inadequate understanding. Previous epidemiological studies based on culture assay have been limited to small study populations. Therefore, data collected by automated systems from a large target population are necessary for more comprehensive understanding of candiduria in hospitalized patients.

Methods

To determine the performance of the Sysmex UF-1000i in detecting candiduria, a cross-sectional study was designed and conducted. A total of 203 yeast-like cell (YLC)-positive and 127 negative samples were randomly chosen and subjected to microbiologic analysis. The receiver operating characteristic curve (ROC) was used to evaluate the ability of YLC counts as measured by the Sysmex UF1000i to predict candiduria. Urinalysis data from 31,648 hospitalized patients were retrospectively investigated, and statistical analysis was applied to the data collected.

Results

Using a cutoff value of 84.6 YLCs/µL, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the yeast like cell (YLC) counts to predict candiduria were 61.7%, 84.1%, 88.6% and 66.3%, respectively. C. glabrata (33.6%) and C. tropicalis (31.4%) were more prevalent than C. albicans (24.3%) in the present study. Of the investigated hospitalized patients, 509 (1.61%) were considered candiduria-positive. Age, gender and basic condition were associated with candiduria in hospitalized patients. In the ICU setting, urinary catheterization appeared to be the only independent risk factor contributing to candiduria according to our investigation. Although antibiotic therapy has been reported to be a very important risk factor, we could not confirm its significance in ICU candiduria patients because of excessive antibiotic usage in our hospital.

Conclusions

The YLC measured by Sysmex UF-1000i is a practical and convenient tool for clinical candiduria screening prior to microbiologic culture. Candiduria is common in hospitalized patients, and its incidence varies according to age, gender and the wards where it is isolated. Candiduria had no direct connection with mortality but might be considered a marker of seriously ill patients who need particular attention in the clinic.

Performance of yeast-like cell counting (YLCC) using the Sysmex UF-1000i for clinical candiduria screening

Candiduria is common in clinical practice. However, an effective and convenient assay to screen for candiduria is still needed. This study aimed to evaluate the performance of the Sysmex UF-1000i urine analyzer for yeast-like cell counting (YLCC) to screen for candiduria prior to urine culture. We retrospectively analyzed data from 5233 urine samples from 1813 patients, including 837 males and 976 females. Urine culture and urinalysis-obtained YLCC data were used to estimate the performance of YLCC in diagnosing candiduria. Different cutoff values were used to calculate sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The YLCC-positive rates differed according to the Candida colony-forming units (CFU) counts in the urine samples. A sharp drop in YLCC-positive rate (from 64.3 to 22.0%) was observed between the urine groups with 10⁴ CFUs and 10³ CFUs. A cutoff value of 0 YLCs/μL results in the highest Youden index (0.71) with 77.04% sensitivity and 93.68% specificity. In a group of 34 hospitalized candiduria patients with serial urinalysis data, 25 were YLCC-positive before urine culture. In conclusion, YLCC with the Sysmax UF-1000i could serve as an auxiliary technique to exclude culture-negative specimens prior to urine culture. Positive YLCC results could imply candiduria, especially when persistent YLCC-positive results were observed.

Risk factors for Candida urinary tract infections in dogs and cats

BACKGROUND

Candida urinary tract infections occur in both dogs in cats but there is limited data about risk factors.

OBJECTIVE

To identify risk factors for candiduria in dogs in cats.

ANIMALS

Eighteen dogs and 8 cats with candiduria.

METHODS

A retrospective case-control study, using univariate exact logistic regression. Medical records were searched for a diagnosis of Candida and animals with culture-confirmed candiduria were enrolled. Controls had bacterial cystitis (dogs and cats) or cutaneous Malassezia infection (dogs only).

RESULTS

Administration of antibacterial drugs in the 30 days before diagnosis was associated with candiduria in dogs compared to controls with bacterial cystitis (OR 14.5; 95% CI 3.1-66.9) or with Malassezia infection (OR 26.4; 95% CI 3.4-206.7). Antecedent antibacterial drug administration was associated with candiduria in cats (OR 15.7; 95% CI 1.9-132.3). Immunosuppression was associated with candiduria in dogs when compared to controls with Malassezia infection (OR 4.2, 95% CI 1.4-12.8), but not significantly when compared to dogs with bacterial cystitis (OR 2.7, 95% CI 0.9-8.0). Lower urinary tract diseases other than infection were associated with candiduria in cats (OR 6.7, 95% CI 1.6-27.9), but not significantly in dogs (OR 2.5, 95% CI 0.7-8.7). Neither diabetes mellitus nor history of hospitalization was significantly associated with candiduria in either species.

CONCLUSIONS AND CLINICAL IMPORTANCE

The recent administration of antibacterial drug therapy is a potential risk factor for development of candiduria in dogs and cats. Judicious use of antibacterial drugs might help to prevent candiduria.

Treatment of Renal Fungal Ball with Fluconazole Instillation Through a Nephrostomy Tube: Case Report and Literature Review

BACKGROUND Urinary tract candida infection can be due either to hematogenous dissemination of the organism or a retrograde infection. In debilitated or immunosuppressed septic patients, who have upper urinary tract obstruction with renal filling defect, fungal infection should be considered. We report on a patient with sepsis and renal fungal ball who was treated with percutaneous nephrostomy and intravenous antifungal agent, but the patient did not respond so instillation of fluconazole through nephrostomy was given. CASE REPORT A 60-year-old male patient with a known case of diabetes mellitus with refractory urine retention underwent transurethral resection of the prostate. Postoperatively, the patient developed recurrent high-grade fever with left loin pain, and elevated septic parameters; urine and blood culture were positive for Candida albicans. Computed tomography urography showed left hydronephrosis with filling defect in the left renal pelvis with suspected renal fungal ball. Left percutaneous nephrostomy was performed and intravenous fluconazole started but the fever did not subside, therefore, the treatment was changed to anidulafungin. The patient improved but urine from both the bladder and the nephrostomy remained positive for candida. Instillation of fluconazole at 300 mg in 500 mL normal saline was applied through the nephrostomy tube over 12 hours at 40 mL/hour for 7 days. CONCLUSIONS Renal fungal ball is rare but can be serious, especially in immunocompromised patients. Management options for renal fungal ball include intravenous antifungal agents and percutaneous nephrostomy with antifungal instillation of antifungal agents. The objective of this case report was to document treatment success with the use of fluconazole instillation through a nephrostomy tube.

Candiduria in kidney transplant recipients: Is antifungal therapy useful?

A French single-centre retrospective study between 2010 and 2014 was undertaken to assess candiduria's incidence in kidney transplant recipients (KTR), and the use and impact of antifungal treatment on outcome. Candiduria was defined as a urine culture with ≥10³  cfu/mL of Candida species. Candiduria clearance, severe complications and death rates were estimated by Kaplan-Meier methods and the effect of treatment by Cox models. 52/1223 (4.3%) KTR had ≥1 episode of candiduria, 42 (81%) were females, 18 (35%) had diabetes, with an incidence of 2.3/100 person-year of follow-up. Candiduria was asymptomatic in 51 (98%) patients. Candida glabrata was the most frequent pathogen identified. Overall fungal clearance rate was 89%. Antifungal therapy was initiated in only 14 episodes (12%), according to guidelines. Three patients (6%) developed severe complications in the first 2 weeks after transplantation, and 8 (15%) died. Antifungal treatment had no impact on candiduria clearance (HR, 0.6; 95% CI, 0.3-1.1; P = .10), on recurrence rate (HR, 0.5; 95% CI, 0.1-2.3; P = .41) and on the risk of severe complications or death (HR, 1.1; 95% CI, 0.3-4.8; P = .89). Candiduria is rare and usually asymptomatic among KTR. Candiduria management in the immediate post-transplant period deserves careful attention.

Identification and antifungal susceptibility of Candida species isolated from the urine of patients in a university hospital in Brazil

The aim of this study was to identify Candida spp. isolated from candiduria episodes at a tertiary hospital in the Midwest region of Brazil, and to determine their susceptibility profiles to antifungal compounds. From May 2011 to April 2012, Candida spp. isolated from 106 adult patients with candiduria admitted to the University Hospital of the Federal University of Mato Grosso do Sul were evaluated. Both, species identification and susceptibility testing with fluconazole-FLC, voriconazole-VRC, and amphotericin B-AmB were carried out using the Vitek 2. To discriminate species of the C. parapsilosis complex, a RAPD-PCR technique using the RPO2 primer was performed. From the total of 106 isolates, 42 (39.6%) C. albicans and 64 (60.4%) Candida non-albicans (CNA) - 33 C. tropicalis, 18 C. glabrata, 5 C. krusei, 4 C. parapsilosis sensu stricto, 2 C. kefyr, 1 C. lusitaniae, and 1 C. guilliermondii were identified. All isolates were susceptible to AmB and VRC, whereas all C. glabrata isolates presented either resistance (5.6%) or dose-dependent susceptibility (94.4%) to FLC. The study of Candida spp. and their resistance profiles may help in tailoring more efficient therapeutic strategies for candiduria.

Nosocomial Candiduria in the Elderly: Microbiological Diagnosis

Candiduria is associated with high morbidity, mortality, and long hospitalization, involving high costs for the healthcare system. The use of increasingly aggressive treatments has prolonged the lives of patients susceptible to candiduria, namely the immunosuppressed, the premature, and the elderly. Our objective was to evaluate the incidence of nosocomial candiduria and the implicated species in hospitalized patients aged over 80 years old from three Spanish centers during 2012 and 2013. Urine samples received from these patients were cultured and analyzed by flow cytometry in search of leukocyturia, hematuria, proteinuria, and microbial nitrate reductase activity. The isolated yeast species were identified microscopically, by germ tube formation in serum, colony morphology after subculture onto CHROMagar Candida (Becton-Dickinson, UK), assimilation of carbon compounds ID32C (bioMérieux, France), matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDITOF) (Bruker Daltonics, Germany) and, in case of inconsistency, by sequencing of the ITS regions of ribosomal DNA (ITS1-5, 8S-ITS2). Susceptibility tests were also performed. The incidence of candiduria in the elderly population was 10.3%. A total of 155 strains of yeasts were isolated. The predominant species was Candida albicans, followed by Candida glabrata and then Candida tropicalis. Several infrequent species were found; among them, the first isolate of candiduria-producing Candida pulcherrima described in the literature. Our finding should raise concerns about the elderly population, which is probably the most important risk group for candiduria in the present moment, and the emergence of unusual yeast species producing candiduria, which are resistant against the commonly used antifungal agents.

Candiduria: Evidence-based approach to management, are we there yet?

Candiduria is considered one of the most controversial issues in patient management. Neither the diagnosis nor the optimal treatment options are standardized. This is further complicated by lack of defined laboratory criteria for diagnosis as most of the studies were set for bacterial rather than fungal urinary tract infection (UTI). Furthermore, since Candida species is a known commensal of the genitourinary tract its presence in the urine sample adds ambiguity to making a definitive diagnosis of candidal UTI. Guidelines for diagnosis and management of candiduria have changed considerably over the past decades. In 1960s, the condition was believed to be benign with no intervention required. However, over the years new dimensions were added to address the issues associated with candiduria until the latest Infectious Diseases Association of America (IDSA) guidelines were published in 2009, which indicated that there was an increase in the incidence of candiduria caused by more resistant non-Candida albicans species. Further complicating the issue is the observation that candiduria may be the only indicator of a more serious invasive candidiasis, especially in immunocompromised patients. Long-term urinary catheterization is considered to be the most significant risk factor for candiduria followed by antibiotic use and diabetes. Strategies for management are based on the evaluation of candiduria in the context of the clinical setting to determine its relevance and make an appropriate decision about the need for antifungal therapy. Fluconazole is the main drug used for its efficacy and least complications. Other options include bladder irrigation with amphotericin B, flucytosine or parenteral amphotericin B. Since azoles other than fluconazole and all echinocandins are poorly excreted in urine they have been found to be less effective in candiduric patients.

Successful treatment with caspofungin of candiduria in a child with Wilms tumor; review of literature

Symptomatic candiduria often occurs in patients with indwelling bladder catheters or immunocompromised host. Isolation of Candida in urine in high-risk patients should primarily be considered as a marker for candidemia. Hematological and genitourinary malignancies are one of the main risk factors associated with Candida urinary tract infections (CUTI). Fluconazole is a choice for initial treatment of CUTI, but it is fluctuate depending on the patient's condition including renal failure, site of urinary infection and Candida species. Poor glomerular filtration is the main disadvantage echinocandins resulting in very low urinary concentrations. Therefore, echinocandins have prohibited their use in CUTI. Up to now, there are only 10 cases reported in the literatures with highly effective echinocandins in CUTI because of high concentrations in the tissue are needed to control invasive fungal disease. Herein, we report a candiduria followed by renal candidiasis caused by Candida albicans in a 6-year-old Iranian male with a history of Wilms tumor in left kidney. Direct examination of urine specimen revealed an infection due to budding yeast cells with numerous pseudohyphae and growths of C. albicans was reconfirmed by sequencing of ITS rDNA region. MICs in increasing order were as follows: caspofungin (0.016μg/ml), voriconazole (0.125μg/ml), amphotericin B (0.25μg/ml), itraconazole (0.5μg/ml) and fluconazole (2μg/ml). It seems that successful treatment with caspofungin owes achieved high renal tissue concentrations that are unrelated to glomerular filtration. In conclusion, predisposing factors for better outcome are more important than treatment of CUTI, therefore, management of UTI is essential for critically patients.

Characterization and identification of candiduria due to Candida species in diabetic patients

BACKGROUND AND PURPOSE

The presence of Candida yeasts in urine, known as candiduria, is an indicator of infection or colonization of the urinary tract by Candida species. This condition in diabetic patients can be hazardous due to diminished immune system response. The objective of this study was to investigate the incidence of candiduria in diabetic patients and to identify its causative agents. Furthermore, the demographic and laboratory (HbA_1c, urine glucose and pH, urine culture colony count, and fasting blood sugar) data and their possible associations with candiduria were investigated.

MATERIALS AND METHODS

This cross-sectional, descriptive study was performed on 305 diabetic patients referred to the diabetes research center, Hamedan, Iran, during April 2015 to September 2015. Urine and blood specimens were collected and urine analysis, urine culture, FBS, and HbA_1c tests were performed. Positive cases were subjected to colony count and the causative agents were subsequently identified through the routine identification tests, as well as colony color in CHROMagar Candida medium, and the assimilation patterns in API 20 C auxanographic method.

RESULTS

Among the 305 cases, 38 (%12.5) were positive for candiduria. Causative agents were identified as Candidaglabrata (n=19, 50%), C. albicans (n=12, 31.6%), C. krusei (n=4, 10.5%), C. tropicalis (n=2, 5.3%), andC. kefyr (n=1, 2.6%). According to the results of the statistical analyses, there were significant association between candiduria and female gender, high FBS and urine glucose, uncontrolled diabetes (HbA1c ≥8), and acidic urine pH (P<0.05).

CONCLUSION

Considering the high incidence rate of candiduria in diabetic patients, control of diabetes, predisposing factors, and causal relationships between diabetes and candiduria should be highlighted.

[Yeast urinary tract infections. Multicentre study in 14 hospitals belonging to the Buenos Aires City Mycology Network]

BACKGROUND

Urinary tract infections are a frequent ailment in patients in intensive care units. Candida and other yeasts cause 5-12% of these infections. The value of the finding of any yeast is controversial, and there is no consensus about which parameters are adequate for differentiating urinary infections from colonization or contamination.

AIMS

To analyse the epidemiological characteristics of patients with funguria, to determine potential cut-off points in cultures (to distinguish an infection from other conditions), to identify the prevalent yeast species, and to determine the value of a second urine sample.

METHODS

A multicentre study was conducted in intensive care units of 14 hospitals in the Buenos Aires City Mycology Network. The first and second samples of urine from every patient were cultured. The presence of white cells and yeasts in direct examination, colony counts, and the identification of the isolated species, were evaluated.

RESULTS

Yeasts grew in 12.2% of the samples. There was no statistical correlation between the number of white cells and the fungal colony-forming units. Eighty five percent of the patients had indwelling catheters. Funguria was not prevalent in women or in patients over the age of 65. Candida albicans, followed by Candida tropicalis, were the most frequently isolated yeasts. Candida parapsilosis and Candida glabrata appeared less frequently. The same species were isolated in 70% of second samples, and in 23% of the cases the second culture was negative.

CONCLUSIONS

It was not possible to determine a useful cut-off point for colony counts to help in the diagnosis of urinary infections. As in other publications, C. albicans, followed by C. tropicalis, were the most prevalent species.

Susceptibility pattern of uropathogens to ciprofloxacin at the Ghana police hospital

INTRODUCTION

Reports of increasing resistance of uropathogens to antimicrobials is of global concern. Culture and drug susceptibility tests remain a vital guide to effective therapy. The aim of this study was to determine the susceptibility pattern of isolated uropathogens to ciprofloxacin at the Ghana Police Hospital.

METHODS

A total of 705 mid-stream urine samples were collected from patients suspected of having urinary tract infection, and visited the Ghana Police Hospital's laboratory from December 2013 to March 2014. Samples were cultured and isolates identified by standard methods, after which isolates susceptibility to ciprofloxacin was determined.

RESULTS

Prevalence of urinary tract infection among patients' whose samples were analyzed was 15.9%. Predominant uropathogens isolated were E. coli (46.4%), Coliform (41.1%) and Coliform spp. with Candida (6.2%). Other isolates were Pseudomonas spp. (2.7%), Salmonella spp. (1.8%), Candida spp. (0.9%) and Klebsiella spp (0.9%). The overall resistance among the top three isolated uropathogens to ciprofloxacin was 35.9%. Resistance pattern demonstrated by respective isolates to ciprofloxacin were: E. coli (38.5%), Coliform (54.3%), and Coliform spp. with Candida (15%). The other isolates showed 100% sensitivity.

CONCLUSION

This study revealed a relatively high ciprofloxacin resistance among isolated uropathogens, hence, the need for prudent prescribing and use of ciprofloxacin in urinary tract infection management.

Treatment of Fungal Urinary Tract Infection

Funguria, and particularly candiduria, is an increasingly common problem encountered by the practicing urologist and is associated with high-acuity care, indwelling catheters, diabetes mellitus, antibiotic and steroid use, and urinary tract disease. In most cases, candiduria is asymptomatic and follows a benign clinical course with antifungal therapy only required in symptomatic or high-risk cases, because spontaneous resolution is common in patients with asymptomatic colonization. Rarely, invasive infections can occur (such as fungus balls or renal abscesses) and may require percutaneous and endoscopic interventions. This article highlights the workup and treatment of funguria and its related urologic manifestations.

Catheter-associated candiduria: Risk factors, medical interventions, and antifungal susceptibility

BACKGROUND

Catheter-associated candiduria is a common clinical finding in hospitalized patients, especially in the intensive care unit. The objective of this study was to obtain demographic and clinical data regarding the prevalence of Candida spp in catheterized in-patients and the medical interventions provided to these patients in a northern Israeli hospital between 2011 and 2013.

METHODS

Isolation and identification of microorganisms were performed on 1,408 urine culture samples 48 hours after catheter insertion. Antifungal Etest susceptibility tests were carried out on every Candida-positive urine sample. Demographic and clinical data were gathered to determine risk factors and medical interventions.

RESULTS

Candiduria was detected in 146 catheterized in-patients out of the 1,408 patients included in this study. C albicans was detected in most cases (69.1%). Fever was observed in 52 (35.61%) patients, and leukocyturia was observed in 48 cases (32.87%). Diabetes mellitus was associated with C albicans candiduria. There were 93 patients (63.69%) who did not receive any medical intervention for their candiduria.

CONCLUSION

Candida is the second leading pathogen causing catheter-associated urinary tract infection or asymptomatic colonization, whereas previous studies showed Candida as the third leading pathogen. Clinical signs and symptoms, such as fever and laboratory tests, cannot distinguish between asymptomatic colonization and infection. Because the management of catheter-associated candiduria is still controversial, additional studies should be carried out.

Yeasts isolated from nosocomial urinary infections: antifungal susceptibility and biofilm production

BACKGROUND

Urinary Candida infections in the hospital environment are frequent and need to be better understood.

AIMS

To compare the results of antifungal susceptibility profiles of yeasts isolated from patients with urinary infections obtained by broth microdilution method (BM) and by disk diffusion (DD), and also evaluate the capacity of these yeasts to form biofilms.

METHODS

Only yeasts obtained from pure urine cultures with counts higher than 10(5) colony-forming units per milliliter, without bacteria development, of symptomatic patients were included. The isolates were identified by classical methods and the antifungal susceptibility tests were performed with the following drugs: amphotericin B, ketoconazole, fluconazole, itraconazole, voriconazole and caspofungin. The biofilm studies were carried out in polystyrene microtitration plates.

RESULTS

Ninety-five yeasts isolates were analyzed, including 40 Candida albicans, 31 Candida glabrata, 24 Candida tropicalis. In general, the majority of the isolates were susceptible to the tested drugs but some resistance was observed, especially against fluconazole. Great variability in the antifungal susceptibility results was observed with the different tested drugs and a few discrepancies were observed between both methods. We suggest that in case of DD resistance this result should be confirmed by BM, the standard method. C. tropicalis isolates showed high biofilm production (91.7%) compared to C. albicans (82.5%) and C. glabrata (61.3%), with statistical significance (p=0.0129).

CONCLUSIONS

Candiduria in critical patients requires major attention and a better control. The different susceptibility results obtained in this study showed the need to identify yeasts up to the species level, especially in patients with urinary tract infection. The development of techniques of antifungal susceptibility tests can help the clinicians in the empiric treatment of candiduria.

Antimicrobial agent exposure and the emergence and spread of resistant microorganisms: issues associated with study design

Antibiotics are essential agents that have greatly reduced human mortality due to infectious diseases. Their use, and sometimes overuse, have increased over the past several decades in humans, veterinary medicine and agriculture. However, the emergence of resistant pathogens is becoming an increasing problem that could result in the re-emergence of infectious diseases. Antibiotic prescription in human medicine plays a key role in this phenomenon. Under selection pressure, resistance can emerge in the commensal flora of treated individuals and disseminate to others. However, even if the effects of antimicrobial use on resistance is intuitively accepted, scientific rationales are required to convince physicians, legislators and public opinion to adopt appropriate behaviours and policies. With this review, we aim to provide an overview of different epidemiological study designs that are used to study the relationship between antibiotic use and the emergence and spread of resistance, as well as highlight their main strengths and weaknesses.

Diagnosis and inflammatory response of patients with candiduria

Candiduria is common in hospitalised patients, but the clinical relevance is still unclear. This study was done to further our knowledge on detection of and host responses to candiduria. Urines and clinical data from 136 patients in whom presence of yeast was diagnosed by microscopic urinalysis were collected. Diagnosis by standard urine culture methods on blood and MacConkey agar as well as on fungal culture medium (Sabouraud dextrose agar) was compared. Inflammatory parameters (IL-6 and IL-17, Ig) were quantified in the urine and compared with levels in control patients without candiduria. Standard urine culture methods detected only 37% of Candida spp. in urine. Sensitivity was especially low (23%) for C. glabrata and was independent of fungal burden. Candida specific IgG but not IgA was significantly elevated when compared with control patients (P < 0.0001 and 0.07 respectively). In addition, urine levels of IL-6 and IL-17 were significantly higher in candiduric patients when compared with control patients (P < 0.001). Multivariate analysis documented an independent association between an increased IgG (odds ratio (OR) 136.0, 95% confidence interval (CI) 25.7-719.2; P < 0.0001), an increased IL-17 (OR 17.4, 95% CI 5.3-57.0; P < 0.0001) and an increased IL-6 level (OR 4.9, 95% CI 1.9-12.4; P = 0.001) and candiduria. In summary, our data indicate that clinical studies on candiduria should include fungal urine culture and that inflammatory parameters may be helpful to identify patients with clinically relevant candiduria.

Candida urinary tract infections--epidemiology, pathogenesis, diagnosis, and treatment: executive summary

The frequency of infection of the urinary tract due to Candida species is increasing in parallel with the rapid advances of medical progress, and these infections are now among the most common problems facing physicians. Despite this fact, much remains to be learned regarding the pathogenesis, diagnosis, and management of bloodborne (antegrade) kidney infections and ascending (retrograde) invasion of the urinary collecting system. The following is a summary of the in-depth analysis of available information from the literature provided in this journal supplement.

[Recommendations of the Infectious Disease Committee of the French Association of Urology. Diagnosis, treatment and monitoring candiduria]

The candiduria are frequently encountered in urology. We present the recommendations of the Infectious Diseases Committee of the French Association of Urology for diagnosis, treatment and monitoring of urinary tract infections. C. albicans is the most frequently isolated species, representing 60% of the isolates. Immunosuppression, diabetes mellitus, age extremes of life, the presence of catheters or procedures on the urinary tract are risk factors for Candida urinary tract infection. The candiduria is usually asymptomatic and does not need treatment. Only 4-14% of patients with candiduria have symptoms of urinary infection. It is necessary before choosing candiduria isolated on a first urinalysis to eliminate contamination by conducting a second harvest. In patients surveyed, the removal of the material allows the resolution of the candiduria nearly half the time and represents the first step of management. Oral fluconazole is the recommended treatment for cystitis (400 mg on day 1 and 200 mg daily for 7 to 14 days). In cases of pyelonephritis without associated candidemia, the first-line therapy is fluconazole (3-6 mg/kg/day) for 14 days or amphotericin B at a dose of 0.5 to 0.7 mg/kg/day with or not associated to flucytosine when potentially resistant strain (C. glabrata).

Candida infections of the genitourinary tract

All humans are colonized with Candida species, mostly Candida albicans, yet some develop diseases due to Candida, among which genitourinary manifestations are extremely common. The forms of genitourinary candidiasis are distinct from each other and affect different populations. While vulvovaginal candidiasis affects mostly healthy women, candiduria occurs typically in elderly, hospitalized, or immunocompromised patients and in neonates. Despite its high incidence and clinical relevance, genitourinary candidiasis is understudied, and therefore, important questions about pathogenesis and treatment guidelines remain to be resolved. In this review, we summarize the current knowledge about genitourinary candidiasis.