An 86-year-old nursing home resident is hospitalized because of fever for the past two days. His medical problems include cerebrovascular accident, decubitus ulcer, benign prostatic hyperplasia, urinary incontinence, hypertension, and type 2 diabetes mellitus.
Upon admission, his temperature is 38.9 C (102 F), blood pressure is 88/54 mm Hg, pulse is 98/min, and respirations are 18/min. After 2 liters of intravenous normal saline, his blood pressure is 109/68 mm Hg and his pulse is 82/min. Examination reveals decreased breath sounds and crackles at the right lung base. He has a chronic Foley catheter in place that drains clear urine. His decubitus ulcer looks clean. He denies any urinary discomfort and there is no suprapubic or costovertebral tenderness. His leukocyte count is 15,400 cells/µL and his serum creatinine level is 0.9 mg/dL. A chest x-ray reveals a right lower lobe infiltrate.
The patient is started on intravenous antibiotics. Over the subsequent 48 hours, he improves and becomes afebrile. A urine culture from admission grows Candida albicans. Blood cultures show no growth.
Which of the following is the best next step in management?

Question

An 86-year-old nursing home resident is hospitalized because of fever for the past two days.  His medical problems include cerebrovascular accident, decubitus ulcer, benign prostatic hyperplasia, urinary incontinence, hypertension, and type 2 diabetes mellitus.
Upon admission, his temperature is 38.9 C (102 F), blood pressure is 88/54 mm Hg, pulse is 98/min, and respirations are 18/min.  After 2 liters of intravenous normal saline, his blood pressure is 109/68 mm Hg and his pulse is 82/min.  Examination reveals decreased breath sounds and crackles at the right lung base.  He has a chronic Foley catheter in place that drains clear urine.  His decubitus ulcer looks clean.  He denies any urinary discomfort and there is no suprapubic or costovertebral tenderness.  His leukocyte count is 15,400 cells/µL and his serum creatinine level is 0.9 mg/dL.  A chest x-ray reveals a right lower lobe infiltrate.
The patient is started on intravenous antibiotics.  Over the subsequent 48 hours, he improves and becomes afebrile.  A urine culture from admission grows Candida albicans.  Blood cultures show no growth.
Which of the following is the best next step in management?

Quizplus · Accepted Answer

11ec193a_96f4_dcda_853d_7108e70ff2ef_MD0002_00 Candida can infect both the upper and lower urinary tract from either an ascending urinary tract infection or a hematogenous source. However, asymptomatic candiduria frequently occurs in patients with chronic urinary catheters likely due to chronic colonization. Current guidelines recommend urinary catheter removal in patients with asymptomatic candiduria or catheter exchange if catheter removal is not possible. Patients with persistent candiduria (especially diabetics) require imaging (e.g., CT or renal ultrasound) after catheter removal/exchange to rule out hydronephrosis, perinephric abscess, or possible fungus ball (rare complication that may require surgical intervention). Systemic antifungal therapy may lead to antifungal-resistant Candida species and is usually avoided in asymptomatic patients. However, therapy is considered in patients at high-risk for disseminated candidiasis (e.g., adult patients with neutropenia or who are undergoing urologic procedures) (Choices A and B). Symptomatic candiduria (e.g., flank pain, abdominal pain, costovertebral angle tenderness) should be treated with antifungal therapy based on the species of Candida identified, extent of infection, and suspected etiology (e.g., lower urinary tract ascending infection or hematogenous source). This patient improved after initial treatment for pneumonia and has no symptoms of upper or lower urinary tract infection; he only requires catheter exchange for his candiduria. His catheter might have been placed to avoid contamination of the decubitus ulcer. (Choice D) Bladder irrigation with antifungals clears the funguria but only works transiently; it is not recommended for either pyelonephritis or cystitis. This patient is asymptomatic and would not benefit from bladder irrigation with antifungal agents. (Choice E) Since the candiduria in this asymptomatic patient likely represents chronic colonization, repeat urine cultures would not be beneficial or aid in treatment decisions. Educational objective: Asymptomatic candiduria is common in patients with chronic urinary catheters and usually requires catheter removal/exchange. Systemic antifungal therapy is not recommended for asymptomatic candiduria in a normal host. Persistent candiduria after catheter exchange/removal usually requires imaging to evaluate for perinephric abscess, fungus ball, or hydronephrosis. __________ References: Candida urinary tract infections - Treatment (http://www.ncbi.nlm.nih.gov/pubmed/21498839) Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/19191635)

An 86-Year-Old Nursing Home Resident Is Hospitalized Because of Fever