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Mycopathologia 158: 4952, 2004.

2004Kluwer Academic Publishers. Printed in the Netherlands. 49

Candiduria in hospital patients: A study prospective

Claudia Castelo Branco Artiaga Kobayashi1, Orionalda de Fatima Lisboa Fernandes1, Karla

Carvalho Miranda

1

, Efignia Dantas de Sousa

2

& Maria do Rosario Rodrigues Silva

1

1Instituto de Patologia Tropical e Sa ude Publica da Universidade Federal de Goias; Brazil; 2Hospital de

Urgncias de Goinia, Goias-Brazil

Received 8 August 2003; accepted in final form 1 January 2004

Abstract

The presence ofCandidaspecies in the urine is frequent among hospitalized patients. We studied sample urine of

205 hospitalized patients during a 1-year period to determine the incidence of nosocomial candiduria. The yeasts

were isolated in 22% (45/205) urine cultures and risk factors in these patients were analyzed. Candida albicans was

isolated in 35.6% and C. tropicalis (22%) was the second most frequent species isolated. Most patients were women

(57.8%) with a mean age of 48.7 years. The principal risk factors that were observed in patients with candiduria

included antibiotics therapy (100%), urinary catheterization (84.4%), surgical procedure (66.7%), female sex and

extended hospitalization. The efficacy of fluconazole therapy to eradicate Candidafrom urine was demonstrated (p

= 0.05). Of the 23 individuals who received antifungal therapy, candiduria persisted in 9 (39.2%) and of 22 patients

who received no antifungal therapy, the candiduria persisted in 15 (68.2%).

Key words:Candidaspp., nosocomial infections, risk factors

Introduction

The significance of the presence of fungi in the urine

of patients is not clearly understood[1]. Fungal growthmay represent contamination, bladder colonization

related to the presence of indwelling bladder cathet-

ers, fungal bezoar, primary infection or disseminated

mycosis [24].

Among the fungi identified in urine, Candida

species are the most common [57]. Candida spe-

cies have become an increasingly important cause of

urinary tract infections among hospitalized patients,

particularly in intensive care units [4, 8].

Most cases of candiduria occur in patients having

some form of urinary drainage devices [9]. The patho-

physiology of most candiduria cases is thought to beretrograde migration via bladder catheters ofCandida

species inhabiting the genital and perineal areas [5].

The conditions that increase the rates of genitalCan-

didacolonization, such as diabetes mellitus, antibiotic

use, immunosuppressive therapy, extended hospitaliz-

ation, extremes of age and female sex are known risk

factors for candiduria [36, 10].

In this study we investigated prospectively the in-

cidence of risk factors associated with candiduria in

hospital patients.

Patients and methods

Study population: Urine samples were obtained by

catheterization of 205 patients from Hospital de Ur-

gncias de Goinia State of Gois, Brazil, during a

12-month period. All patients agreed to participate in

this study, which was approved by the local Ethics

Committee. Data as sex, age, antifungal therapy and

variables as possible risk factors, included antibiotics,

underlying disease or comorbid condition and stay in

the hospital were collected in patients who had hadat least 1 culture of urine that yielded 103 yeast

colonies/ml. During this same period, this group of pa-

tients with 103 yeast colonies/ml were enrolled in a

prospective, randomized study, comparing fluconazole

with placebo for the treatment of funguria. Patients

were eligible for treatment if two urine cultures that

were performed at least 24 h apart were positive for

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50

yeast. The treatment trial was designated by the study

protocol of Sobel [3].

Culture methods and quantitative culture methods:

The urine samples were spread by calibrated loop

(0.01 ml) onto Sabouraud Dextrose Agar plates sup-

plemented with 100g/ml of chloramphenicol. Plateswere incubated aerobically at 37 C and read 24 hours.

The detection level for quantitative cultures used in

this study was 100 CFU/ml, represented by a single

colony of yeast on a plate [11].Candidaspecies were

identified by germ tube formation in fetal calf serum

at 37 C, colony morphology on cornmeal agar, sugar

fermentation and assimilation tests [12].

Statistical methods: Descriptive statistics, including

means and standard deviations, were used to summar-

ize continuous measures. The data were evaluated by

2X2 contingency tables using the chi-square test. P

values 0.05 were considered to be significant.

Results

Of the 205 urine samples cultured, fungi were re-

covered from 22% (45 patients) from whomCandida

species were isolated. Mean age of the 45 selected sub-

jects was 48.719.8 years (range 1488 years). Yeasts

were isolated from the urine of 26 women (57.8%)

and 19 men (p = 0.001). The length of hospitalization

before candiduria was higher than one week for 80%(36/45) of the patients.

Underlying conditions were present in most pa-

tients (Table 1). The most common risk factors were

antibiotic therapy (100%) before the detection of

yeasts and indwelling urinary catheter (84.4%), and

more than half of patients had had a surgical procedure

performed within the preceding month.

The yeasts isolated from urine are shown in Table

2. The predominant specie was Candida albicans

isolated from urine of 35.6% of the patients (16/45)

followed by C. tropicalis isolated in 22% patients

(10/45). Of the 45 patients, 23 (51.1%) received treat-ment with fluconazole (200 mg daily for 14 days and

22 (48.9%) received no antifungal therapy. The effic-

acy of fluconazole to eradicate Candida from the urine

was clearly demonstrated (p < 0.05). At the end of

antifungal therapy candiduria cleared in 14 (60.8%)

of the 23 patients treated with fluconazole and in 7

(31.8%) of the 22 patients no treated.

Table 1. Risk factors for Candidaspecies funguria

Risk factors No. of patients (%)

Antibiotic therapy 45 (100)

Indwelling urinary catheters 38 (84.4)

Surgical procedures 30 (66.7)

ITU 13 (28.9)

Female 26 (57.8)

Old age (higher than 60 years) 14 (31.1)

Diabetes 12 (26.7)

Immunosuppressive agents 3 (6.7)

Table 2. Candida species in patients with

candiduria

Species No. identified (%)

C. albicans 16 (35.6)

C. tropicalis 10 (22.2)

C. pseudotropicalis 5 (11.1)C. parapsilosis 5 (11.1)

C. glabrata 4 (8.9)

C. krusei 3 (6.7)

C. guilliermondii 2 (4.4)

Discussion

A broad diversity of number of species of Candida

was seen in this study. The incidence of candiduria

caused by species other thanC. albicanswas surpris-ingly high. Candida tropicalis (22.2%) was the most

common of the non albicans species isolated, and a

proportion of 42.2% of other non albicans yeasts was

found. Other studies have documented that species

non albicans have accounted in urine [13]. Febr et

al. [14] isolated C. albicans (46.1%) followed ofC.

glabrata (30.7%) and C. krusei (7.7%) from urine

specimens.

Despite many risk factors have been suggested to

funguria, we observed that antibiotic therapy, indwell-

ing urinary catheter, surgical procedures, female sex

and extended hospitalization were more common inpatients studied.

In this present work, Candidagrowth in urine was

broadly associated with antibiotic therapy. By sup-

pressing susceptible endogenous bacterial flora in the

gastrointestinal and lower genital tract, antibiotic use

results in fungal colonization of epithelial surface with

ready access to the urinary tract, especially in the pres-

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51

ence of indwelling bladder catheters [5]. Most cases

of candiduria (84.4%) occurred in patients that had

had indwelling urinary catheter, which is one the most

important risk factor for funguria. However, remov-

ing or changing the catheter could eradicate funguria

[15]. In a prospective, multicenter controlled study,

Sobel et al. [7] found that asymptomatic candiduria re-solved with catheter removed in 41% of hospitalized

catheterized patients.

A previous surgery was a factor associated with

funguria (66.7%). However surgery per se or the

need for a urinary drainage device in the perioperat-

ive period as the most important factor could not be

determined.

The actual onset of nosocomial funguria has not

been characterized. In our study 20% (9/45) of the

cases of funguria developed during the first week of

hospitalization, but the most (80%) after first week.

Two studies found that funguria developed after three

weeks of hospitalization, while the others indicated

that funguria can develop during the first two weeks

[13, 16, 17].

The incidence of candiduria was higher in females

(57.8%) than in males. The high incidence in females

may reflect vaginal candidiasis. Yeasts may ascend

from the genitourinary tract to the urinary tract, ex-

plaining the greater incidence of candiduria in women

[14]. This hypothesis was suggested by Febr et al.

[14] that found five of the eight patients with posit-

ive vaginal secretions later showed the presence of the

same yeast species in their urine.

The isolation of yeast cells from urine is a com-mon occurrence in patients hospitalized. However,

there is considerable controversy about whether and

when to treat asymptomatic candiduria. In some cases,

as those patients with particular risk for progress-

ive disease, the funguria therapy should be indicated

[18]. In our study the treatment with fluconazole in

23 patients eradicated funguria in 60.8%, which was

higher than the rates of 31.8%obtained in patients who

not received treatment. Sobel et al. [7] randomized

238 patients with asymptomatic candiduria to receive

fluconazole for 14 days or placebo, verifying higher

eradication ofCandida species from the urine in pa-

tients who received fluconazole therapy than in the

placebo groups. However, resolution spontaneous has

been found in retrospectives studies of asymptomatic

funguria [6, 18].

In conclusion, candiduria is common in patients

with serious comorbid conditions and may be re-

solved spontaneously depending upon whether the risk

factors can be corrected. When treatment of asympto-

matic candiduria is indicated, oral fluconazole should

be used since it is efficient in eradicating Candida in

urine.

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Address for correspondence: Dra. Maria do Rosrio Rodrigues

Silva, Instituto de Patologia Tropical e Sade Pblica, Rua Delenda

Rezende de Melo esq. com 1z Avenida. Setor Universitrio, Caixa

Postal 131, CEP 74605-050, Goinia-GO, Brasil

Tel.: (0xx62) 2096127; Fax: (0xx62) 5211839;

E-mail: rosario@iptsp.ufg.br