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Management of Candida Urinary Tract Infection in The Elderly
Management of Candida Urinary Tract Infection in The Elderly
Management of Candida Urinary Tract Infection in The Elderly
https://doi.org/10.14777/uti.2019.14.2.33
Review Urogenit Tract Infect 2019;14(2):33-41
http://crossmark.crossref.org/dialog/?doi=10.14777/uti.2019.14.2.33&domain=pdf&date_stamp=2019-8-25
Sang Jin Kim, Jae Hyun Ryu, Yun Beom Kim, Seung Ok Yang
Candida urinary tract infections in elderly patients are becoming increasingly Received: 23 April, 2019
common. The risk factors for the development of candiduria include old age, use Revised: 10 May, 2019
Accepted: 10 May, 2019
of broad-spectrum antibiotics, corticosteroids and indwelling urethral catheters,
as well as diabetes mellitus, urological abnormalities, and hematological malig-
nancies. 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 treat-
ment. 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.
33
34 Sang Jin Kim, et al. Management of Candiduria in Elderly Patients
1. Hematogenous Route If Candida UTI occurs in the bladder, the patients report
Hematogenous seeding is the most common route of renal urinary urgency, urinary frequency, dysuria, suprapubic
infections, such as renal candidiasis during an episode of discomfort, and pneumaturia, similar to the symptoms of
candidemia. Although this event is usually asymptomatic bacterial cystitis. The systemic symptoms and signs of in-
with regard to urinary symptoms, many experimental animal fection are usually absent if the infection is confined to the
studies have reported the development of multiple micro- bladder. On the other hand, if patients have an indwelling
abscesses throughout the cortex after intravenous admini- bladder catheter, they do not have lower urinary tract symp-
stration of C. albicans [34]. After the fungi penetrate through toms and usually complain of few symptoms [39]. Patients
the glomeruli into the proximal tubules, the fungi are shed in the ICU are often unable to communicate any symptoms
into the urine [35]. Autopsy studies have revealed the pre- that they might have. This ambiguity of symptoms makes
sence of renal cortical microabscesses in most patients who it difficult to differentiate between infection and coloni-
die with invasive candidiasis [36]. zation.
If a fungus ball, which is a mass of hyphae and yeast
2. Ascending Route cells, is formed in the collecting system, the patients may
Retrograde ascending infections are the most common complain of increasing flank pain and may become oliguric.
routes for genitourinary tract infections. This infection is If the fungal ball leads to a ureteral obstruction, acute colicky
observed more often in females than males because females flank pain and fever may develop [40]. A fungus ball that
have a shorter urethra and frequently have a vulvovaginal forms in the bladder can remain asymptomatic until it
colonization of organisms. Although the pathogenesis of obstructs the ureters and/or urethra.
ascending infection by Candida has not been studied ex- Elderly patients often present with atypical signs and
tensively, spread from the perineum into the bladder leads symptoms of infection, and a delayed diagnosis is possible
to colonization and then retrograde spread leads to an in- if combined with altered mentality [41].
fection of the upper urinary tract, particularly concomitant
with vesicoureteral reflux or an obstruction of urinary flow
[34,37]. Urethral catheterization can lead to infection by the
DIAGNOSIS TREATMENT
When candidal organisms are present in the urine, the The risk of developing candidemia from candiduria is low.
major concern is whether this finding represents a significant In a large prospective surveillance study, only seven (1.3%)
infection of the urinary tract, colonization of the bladder, out of 530 patients with candiduria developed candidemia
or contamination of the urine sample [42]. Unfortunately, after a 10 week follow-up [3]. A similar study reported that
there is no optimal sensitive diagnostic method available only five out of 233 patients with candiduria in the ICU
to distinguish these different possibilities, and a clinical developed candidemia due to the same species 2 to 15 days
assessment must be relied on in many circumstances. later [43]. In a clinical and molecular analysis to examine
The contamination of a urine specimen is common, the relationship between candidemia and concomitant
particularly if the specimen is from a catheterized patient candiduria, only four (2.8%) of cases with candidemia showed
or a female with heavy yeast colonization of the vulvovaginal the genotypic same species of Candida strains between two
area. Therefore, it is wise to first repeat the urine culture specimens [44]. For these reasons, the significance and the
and ensure that a clean-catch midstream urine specimen necessity of treatment are often uncertain.
has been obtained. Aseptic bladder catheterization should Prior to treatment, persistent indwelling urinary catheters
be conducted to obtain a urine sample if the patient is unable should be removed, if possible, because catheters make the
to perform clean-catch midstream urine collection. If the eradication of candiduria very difficult. After removing the
second sample does not yield organisms, it indicates the catheter without administering antifungal agents, the fol-
previous result was from contamination, so further workup lowing urine culture could show a negative result of can-
is not needed. diduria [3].
If candiduria is found in a patient with an indwelling When administering antifungal agents, an obstruction of
catheter, the catheter should be removed, if possible. A urine flow in the genitourinary tract should be considered
second sample should be obtained several days later to see and bacteriuria should be treated first. Antifungal agents
if the candiduria has disappeared. If so, further workup is could be ineffective if urine flow is obstructed. In addition,
not needed. In patients who require a catheter, the catheter by treating the concomitant bacteriuria with antibacterial
should be replaced and a urine sample should be collected therapy, the patient’s symptoms may be improved and
through the new catheter. If the candiduria has disappeared, antifungal therapy might not be needed.
the first sample likely represents colonization and no more If the infection relapses or fails to clear despite treatment,
workup is needed. an imaging study, voiding function test, such as urodynamic
In patients with persistent candiduria, the major concern studies, and cystoscopy, should be performed. Prostatic
is whether there is bladder colonization, cystitis, or upper abscess, bladder fungus ball, and chronic bladder changes
tract infection. The clinical manifestations and laboratory can all affect the relapse or treatment failure. If obstructive
studies can be useful for establishing whether a patient has uropathy is detected in patients with an upper urinary tract
a Candida UTI. Candida infection, the obstruction should be resolved by
Diagnostic imaging can be an important evaluation. Ex- a percutaneous nephrostomy or a ureteral stent.
cretory urography can detect hydronephrosis when ob-
structive uropathy, non-functioning kidney, or a fungus ball 1. Asymptomatic Candiduria
in the collecting system is present. In patients in the ICU Generally, asymptomatic candiduria should not be treated
or with impaired renal function, ultrasonography is the except under specific circumstances, such as patients under-
preferred initial examination because of its portability and going urological procedures, neutropenic patients, and very
absence of renal toxicity. Computed tomography, magnetic low birth weight neonates (<1,500 g). In a randomized
resonance imaging, and renal scintigraphy are sensitive double-blind study of treatment with fluconazole and place-
methods for detecting renal abscesses, fungus balls, and bo for asymptomatic candiduria patients, fluconazole ther-
nonfunctioning kidneys. apy initially showed high eradication rates, but urine cultures
at two weeks showed similar candiduria rates among the
treated and untreated patients [45]. Candida cystitis. The most common dose is 50 mg ampho-
In patients with candiduria, who undergo a urological tericin B diluted in 1 L of sterile water to give a concentration
procedure, the risk of candidemia following urinary tract of 50 µg/ml [52]. On the other hand, the relapse rate after
instrumentation is high. Therefore, treatment with fluco- bladder irrigation is high and this strategy is rarely needed
nazole should be given before and immediately after the except for persistent cystitis by fluconazole-resistant organ-
procedure [46,47]. Neutropenic patients with candiduria isms [53].
should be treated because neutropenia can minimize any Renal parenchymal infection is generally the result of an
related symptoms, indicating a high likelihood that can- antegrade infection and is treated the same as candidemia.
diduria reflects the upper tract infection and candidemia Retrograde infections of the kidneys can also develop due
[48]. In very low birth weight neonates, candiduria is often to the retrograde spread of the organism in patients with
a marker of invasive candidiasis and infections of the upper obstructive uropathy, DM, and concomitant bacteriuria.
urinary tract. Therefore, although related symptoms are not Fluconazole is the agent of choice for pyelonephritis [48].
observed, candiduria should always be treated in this popu- Generally, a daily oral dose of 400 mg for two weeks is
lation [22]. recommended. Flucytosine or intravenous amphotericin B
In patients with an indwelling urethral catheter and injection may be necessary in patients who have organisms
asymptomatic candiduria, treatments with antifungal agents resistant to fluconazole. The recommended dose of flu-
are ineffective in eradicating candiduria and the long-term cytosine and intravenous amphotericin B for Candida pye-
clinical outcomes will not improve [49]. lonephritis is the same as with Candida cystitis, but the
duration is slightly longer: 14 days for both drugs [23,51].
performed if a perinephric abscess is detected. show adequate concentrations in the urine, and failure of
A fungus ball should be treated with medical therapy and these formulations has been reported [54].
surgical or radiological interventions. Systemic therapy is Flucytosine is also valuable in treating fluconazole-
effective because these luminal aggregates of hyphae and resistant C. glabrata-induced UTI. Flucytosine achieves high
necrotic tissues often result from systemic candidiasis or concentrations in the urine and is active against many
deeply disseminated parenchymal infection. Fluconazole is isolated C. glabrata. On the other hand, C. krusei is not
the mainstay of therapy. Although antifungal agent therapy susceptible to flucytosine. The recommended dose is 25
can result in spontaneous disruption and passage of the mg/kg every six hours daily for 7 to 10 days and 14 days
hyphal mass filament and debris, it is not sufficient to for cystitis and upper UTI, respectively [48,51]. Nevertheless,
eliminate the fungus ball completely [59]. An invasive this dosage is associated with the likelihood of bone marrow
procedure is almost always required to relieve the ob- toxicity; thus, a lower dosage of 25 mg/kg every eight hours
struction and remove the mass. If access to the renal pelvis daily is preferred, but this dosage should be adjusted
through nephrostomy tubes is available, local irrigation with according to the level of creatinine clearance [23]. Complete
amphotericin B or fluconazole can be considered [60,61]. blood cell counts and close monitoring of the patients for
Intermittent saline irrigation, percutaneous endoscopic dis- rash, diarrhea, or other gastrointestinal complaints are
ruption and drainage, and percutaneous irrigation with necessary. Hepatotoxicity is associated with flucytosine in
streptokinase can also be performed to facilitate the break- up to 41% of patients.
down and passage of fungus balls [62,63].
CONCLUSIONS
4. Antifungal Agent
The selection of an appropriate antifungal agent must Candiduria is observed predominantly in a nosocomial
consider the antifungal susceptibility of the organism and setting and is an uncommon finding in healthy people. On
the ability of the antifungal agent to achieve the adequate the other hand, patients with specific risk factors are
concentrations in the urine. vulnerable to Candida UTI. The optimal therapy for Candida
Oral fluconazole, which is excreted into the urine as an UTI remains uncertain. Interventions for eliminating the
active drug and achieves high urine levels, is the agent of predisposing factors, such as aggravating infections, should
choice for the treatment of Candida UTI [48]. Most Candida be implemented regardless of whether drug therapy is used.
species are susceptible to fluconazole, including C. albicans, Decisions regarding the use of drug therapy, including the
which is the most commonly cultured Candida, and flu- choice of agent, method of administration, and treatment
conazole is effective for infections of both the upper and duration, should be based on the medical condition of the
lower urinary tract. In particular, C. glabrata is often resistant patient and local epidemiology.
to fluconazole, and C. krusei is uniformly resistant to flu- In elderly people, Candida UTI has become an in-
conazole. Unlike fluconazole, the other azole agents, such creasingly important problem. Antifungal agent admini-
as itraconazole, posaconazole, and voriconazole, are meta- stration must be used with caution because elderly patients
bolized in the liver, and urinary excretion is either minimal are usually already taking a number of medications and the
or absent. Therefore, except for fluconazole, the other azole risk of drug-drug interactions is more likely. When a
agents are not recommended for the treatment of Candida therapeutic regimen is planned, comorbidities and multidrug
UTI. use should be considered. Elderly patients can be colonized
If fluconazole is ineffective, intravenous amphotericin B more easily by pathogenic fungi and have an increased
deoxycholate may effective in treating Candida UTI and is incidence of C. glabrata infection, which has higher rates
the treatment of choice for UTI from C. glabrata or C. krusei. of mortality and resistance to fluconazole.
The recommended dose is 0.3 to 1.0 mg/kg per day for 5
to 7 days, but even a single-dose with 0.2 to 1.0 mg/kg has CONFLICT OF INTEREST
been shown to be effective [64]. The lipid formulations of
amphotericin B, which show reduced nephrotoxicity, do not No potential conflict of interest relevant to this article
was reported. a persistent public health problem. Clin Microbiol Rev 2007;
20:133-63.
10. Dimopoulos G, Paiva JA, Meersseman W, Pachl J, Grigoras I,
ACKNOWLEDGMENTS Sganga G, et al. Efficacy and safety of anidulafungin in elderly,
critically ill patients with invasive Candida infections: a post
This study was supported by a VHS Medical Center Re-
hoc analysis. Int J Antimicrob Agents 2012;40:521-6.
search Grant, Republic of Korea (grant number: VHSMC 11. Flevari A, Theodorakopoulou M, Velegraki A, Armaganidis A,
19018). Dimopoulos G. Treatment of invasive candidiasis in the elderly:
a review. Clin Interv Aging 2013;8:1199-208.
12. Bouza E, San Juan R, Munoz P, Voss A, Kluytmans J; Co-
AUTHOR CONTRIBUTIONS operative Group of the European Study Group on Nosocomial
Infections. A European perspective on nosocomial urinary tract
S.O.Y. participated in the study design. S.J.K. participated
infections I. Report on the microbiology workload, etiology and
in data collection and wrote the manuscript. J.H.R. and Y.B.K. antimicrobial susceptibility (ESGNI-003 study). European Study
participated in coordination and helped to draft the Group on Nosocomial Infections. Clin Microbiol Infect 2001;
manuscript. All authors read and approved the final 7:523-31.
manuscript. 13. Sobel JD, Fisher JF, Kauffman CA, Newman CA. Candida urinary
tract infections--epidemiology. Clin Infect Dis 2011;52 Suppl
6:S433-6.
ORCID 14. Kobayashi CC, de Fernandes OF, Miranda KC, de Sousa ED,
Silva Mdo R. Candiduria in hospital patients: a study pro-
Sang Jin Kim, https://orcid.org/0000-0002-4556-5676 spective. Mycopathologia 2004;158:49-52.
Jae Hyun Ryu, https://orcid.org/0000-0003-3605-8717 15. Safdar N, Slattery WR, Knasinski V, Gangnon RE, Li Z, Pirsch JD,
Yun Beom Kim, https://orcid.org/0000-0002-7331-3871 et al. Predictors and outcomes of candiduria in renal transplant
Seung Ok Yang, https://orcid.org/0000-0001-8526-2023 recipients. Clin Infect Dis 2005;40:1413-21.
16. Nguyen MH, Peacock JE Jr, Morris AJ, Tanner DC, Nguyen ML,
Snydman DR, et al. The changing face of candidemia: emer-
REFERENCES gence of non-Candida albicans species and antifungal resist-
ance. Am J Med 1996;100:617-23.
1. Rivett AG, Perry JA, Cohen J. Urinary candidiasis: a prospective 17. Malani PN, Bradley SF, Little RS, Kauffman CA. Trends in species
study in hospital patients. Urol Res 1986;14:183-6. causing fungaemia in a tertiary care medical centre over 12
2. Hamory BH, Wenzel RP. Hospital-associated candiduria: pre- years. Mycoses 2001;44:446-9.
disposing factors and review of the literature. J Urol 1978; 18. Pfaller MA, Diekema DJ. Role of sentinel surveillance of can-
120:444-8. didemia: trends in species distribution and antifungal sus-
3. Kauffman CA, Vazquez JA, Sobel JD, Gallis HA, McKinsey DS, ceptibility. J Clin Microbiol 2002;40:3551-7.
Karchmer AW, et al. Prospective multicenter surveillance study 19. Pfaller MA, Diekema DJ, Jones RN, Messer SA, Hollis RJ;
of funguria in hospitalized patients. Clin Infect Dis 2000;30: SENTRY Participants Group. Trends in antifungal susceptibility
14-8. of Candida spp. isolated from pediatric and adult patients with
4. Ayeni O, Riederer KM, Wilson FM, Khatib R. Clinicians' reaction bloodstream infections: SENTRY Antimicrobial Surveillance
to positive urine culture for Candida organisms. Mycoses Program, 1997 to 2000. J Clin Microbiol 2002;40:852-6.
1999;42:285-9. 20. Guinea J. Global trends in the distribution of Candida species
5. Storfer SP, Medoff G, Fraser VJ, Powderly WG, Dunagan WC. causing candidemia. Clin Microbiol Infect 2014;20 Suppl 6:
Candiduria: retrospective review in hospitalized patients. 5-10.
Infect Dis Clin Pract 1994;3:23-9. 21. Malani A, Hmoud J, Chiu L, Carver PL, Bielaczyc A, Kauffman
6. Harris AD, Castro J, Sheppard DC, Carmeli Y, Samore MH. Risk CA. Candida glabrata fungemia: experience in a tertiary care
factors for nosocomial candiduria due to Candida glabrata and center. Clin Infect Dis 2005;41:975-81.
Candida albicans. Clin Infect Dis 1999;29:926-8. 22. Phillips JR, Karlowicz MG. Prevalence of Candida species in
7. Jacobs LG. Fungal urinary tract infections in the elderly: treat- hospital-acquired urinary tract infections in a neonatal in-
ment guidelines. Drugs Aging 1996;8:89-96. tensive care unit. Pediatr Infect Dis J 1997;16:190-4.
8. Kauffman CA. Fungal infections in older adults. Clin Infect Dis 23. Kauffman CA. Diagnosis and management of fungal urinary
2001;33:550-5. tract infection. Infect Dis Clin North Am 2014;28:61-74.
9. Pfaller MA, Diekema DJ. Epidemiology of invasive candidiasis: 24. Hof H, Mikus G. [Candida infections in the elderly]. Z Gerontol
Geriatr 2013;46:64-70. German. patients admitted to intensive care units in France: incidence,
25. Aw D, Silva AB, Palmer DB. Is thymocyte development func- molecular diversity, management and outcome. Intensive Care
tional in the aged? Aging (Albany NY) 2009;1:146-53. Med 2008;34:292-9.
26. Colonna-Romano G, Buffa S, Bulati M, Candore G, Lio D, 44. Drogari-Apiranthitou M, Anyfantis I, Galani I, Kanioura L,
Pellicanò M, et al. B cells compartment in centenarian offspring Daikos GL, Petrikkos G. Association between candiduria and
and old people. Curr Pharm Des 2010;16:604-8. candidemia: a clinical and molecular analysis of cases. Myco-
27. Deray G. Amphotericin B nephrotoxicity. J Antimicrob Che- pathologia 2017;182:1045-52.
mother 2002;49 Suppl 1:S37-41. 45. Sobel JD, Kauffman CA, McKinsey D, Zervos M, Vazquez JA,
28. Stine JG, Sateesh P, Lewis JH. Drug-induced liver injury in the Karchmer AW, et al. Candiduria: a randomized, double-blind
elderly. Curr Gastroenterol Rep 2013;15:299. study of treatment with fluconazole and placebo. Clin Infect
29. Woodhouse K, Wynne HA. Age-related changes in hepatic Dis 2000;30:19-24.
function. Implications for drug therapy. Drugs Aging 1992;2: 46. Ang BS, Telenti A, King B, Steckelberg JM, Wilson WR. Can-
243-55. didemia from a urinary tract source: microbiological aspects
30. Tulner LR, Kuper IM, Frankfort SV, van Campen JP, Koks CH, and clinical significance. Clin Infect Dis 1993;17:662-6.
Brandjes DP, et al. Discrepancies in reported drug use in 47. Gross M, Winkler H, Pitlik S, Weinberger M. Unexpected
geriatric outpatients: relevance to adverse events and drug- candidemia complicating ureteroscopy and urinary stenting.
drug interactions. Am J Geriatr Pharmacother 2009;7:93-104. Eur J Clin Microbiol Infect Dis 1998;17:583-6.
31. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers 48. Pappas PG, Kauffman CA, Andes D, Benjamin DK Jr, Calandra
MH. Updating the Beers criteria for potentially inappropriate TF, Edwards JE Jr, et al; Infectious Diseases Society of America.
medication use in older adults: results of a US consensus panel Clinical practice guidelines for the management of candidiasis:
of experts. Arch Intern Med 2003;163:2716-24. 2009 update by the Infectious Diseases Society of America.
32. Gallagher P, Barry P, O'Mahony D. Inappropriate prescribing in Clin Infect Dis 2009;48:503-35.
the elderly. J Clin Pharm Ther 2007;32:113-21. 49. Yang SO. Catheter-associated urinary tract infection. Korean J
33. Wey SB, Mori M, Pfaller MA, Woolson RF, Wenzel RP. Risk Urogenit Tract Infect Inflamm 2013;8:73-82.
factors for hospital-acquired candidemia. A matched case- 50. Auger P, Dumas C, Joly J. A study of 666 strains of Candida
control study. Arch Intern Med 1989;149:2349-53. albicans: correlation between serotype and susceptibility to
34. Fisher JF, Kavanagh K, Sobel JD, Kauffman CA, Newman CA. 5-fluorocytosine. J Infect Dis 1979;139:590-4.
Candida urinary tract infection: pathogenesis. Clin Infect Dis 51. Fisher JF, Sobel JD, Kauffman CA, Newman CA. Candida urinary
2011;52 Suppl 6:S437-51. tract infections--treatment. Clin Infect Dis 2011;52 Suppl
35. MacCallum DM, Odds FC. Temporal events in the intravenous 6:S457-66.
challenge model for experimental Candida albicans infections 52. Goldman HJ, Littman ML, Oppenheimer GD, Glickman SI.
in female mice. Mycoses 2005;48:151-61. Monilial cystitis-effective treatment with instilations of ampho-
36. Kauffman CA. Candiduria. Clin Infect Dis 2005;41 Suppl 6: tericin B. JAMA 1960;174:359-62.
S371-6. 53. Drew RH, Arthur RR, Perfect JR. Is it time to abandon the use of
37. Achkar JM, Fries BC. Candida infections of the genitourinary amphotericin B bladder irrigation? Clin Infect Dis 2005;40:
tract. Clin Microbiol Rev 2010;23:253-73. 1465-70.
38. Siddique MS, Gayed N, McGuire N, Khatilb R. Salient features 54. Agustin J, Lacson S, Raffalli J, Aguero-Rosenfeld ME, Wormser
of Candida pyelonephritis in adults. Infect Dis Clin Pract 1992; GP. Failure of a lipid amphotericin B preparation to eradicate
1:240-5. candiduria: preliminary findings based on three cases. Clin
39. Tambyah PA, Maki DG. Catheter-associated urinary tract in- Infect Dis 1999;29:686-7.
fection is rarely symptomatic: a prospective study of 1,497 55. Wise GJ, Shteynshlyuger A. How to diagnose and treat fungal
catheterized patients. Arch Intern Med 2000;160:678-82. infections in chronic prostatitis. Curr Urol Rep 2006;7:320-8.
40. You JH, Kim MK. Bacterial urosepsis by a fungal ball mimicking 56. Bartkowski DP, Lanesky JR. Emphysematous prostatitis and
a ureteral stone. Korean J Urogenit Tract Infect Inflamm 2014; cystitis secondary to Candida albicans. J Urol 1988;139:1063-
9:115-8. 5.
41. Jacobs LG, Skidmore EA, Cardoso LA, Ziv F. Bladder irrigation 57. Giannopoulos A, Giamarellos-Bourboulis EJ, Adamakis I,
with amphotericin B for treatment of fungal urinary tract in- Georgopoulou I, Petrikkos G, Katsilambros N. Epididymitis
fections. Clin Infect Dis 1994;18:313-8. caused by Candida glabrata: a novel infection in diabetic
42. Fisher JF, Newman CL, Sobel JD. Yeast in the urine: solutions for patients? Diabetes Care 2001;24:2003-4.
a budding problem. Clin Infect Dis 1995;20:183-9. 58. Jenkin GA, Choo M, Hosking P, Johnson PD. Candidal epididymo-
43. Bougnoux ME, Kac G, Aegerter P, d'Enfert C, Fagon JY; CandiRea orchitis: case report and review. Clin Infect Dis 1998;26:942-5.
Study Group. Candidemia and candiduria in critically ill 59. Fisher J, Mayhall G, Duma R, Shadomy S, Shadomy J,
Watlington C. Fungus balls of the urinary tract. South Med J 62. Chitale SV, Shaida N, Burtt G, Burgess N. Endoscopic man-
1979;72:1281-4, 1287. agement of renal candidiasis. J Endourol 2004;18:865-6.
60. Chung BH, Chang SY, Kim SI, Choi HS. Successfully treated 63. Kabaalioğlu A, Bahat E, Boneval C. Renal candidiasis in a
renal fungal ball with continuous irrigation of fluconazole. J 2-month-old infant: treatment of fungus balls with
Urol 2001;166:1835-6. streptokinase. AJR Am J Roentgenol 2001;176:511-2.
61. Bartone FF, Hurwitz RS, Rojas EL, Steinberg E, Franceschini R. 64. Fisher JF, Woeltje K, Espinel-Ingroff A, Stanfield J, DiPiro JT.
The role of percutaneous nephrostomy in the management of Efficacy of a single intravenous dose of amphotericin B for
obstructing candidiasis of the urinary tract in infants. J Urol Candida urinary tract infections: further favorable experience.
1988;140:338-41. Clin Microbiol Infect 2003;9:1024-7.