Fungal
Urinary Tract Infections
Diagnosis and
Management
Tristan T. Berry, M4
Medical College of Virginia
Objectives
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History
Definition of the fungal UTI.
Epidemiology
Predisposing conditions
Presenting symptoms
Common organisms and important rare organisms
Diagnosis imaging ,cytology/culture (blood and urine)
Treatment
Resistance to antifungals
History
1890 Schmorl reports renal involvement in patient
with disseminated candidiasis.
1910 Rafin recognizes candidal cystitis
1931 Lundquist reports primary renal mycosis
1948 Moulder reports cystoscopic findings of
candidiasis in the urinary bladder
1963 Twelve cases of candidal infection of the
kidney reported
1980 Increased reporting of fungal infection of
urinary tract . Likely multifactorial.
Epidemiology and Predisposing Factors
Fungal pathogens are the cause of
increasing nosocomial infections in
hospital communities.
Epidemiology and Predisposing Factors
From 1980-1990 the nosocomial fungal infection
rate for urinary tract infections had risen from
9.0 to 20.5 per 10,000 hospitalized patients.
Epidemiology and Predisposing Factors
Three distinct groups of pathogens are noted
for causing fungal UTIs:
1) Opportunistic organisms
2) Environmental
3) Rare and unusual
Opportunistic Organisms
• normally inhabit human flora or environment.
• proliferate when there is a defect in an
individual's immune system. Thus causing
disease.
• Candida species - saprophytes of the skin,
oropharyx ,gasrointestinal tract and genital
regions.
Environmental
• include Blastomyces, Histoplasmosis,
Coccidoides.
• found primarily in soil,environment and guano.
inhabit human flora or environment.
Rare and unusual
• Mucormycosis and others
Opportunistic Fungi
C. Albicans
• oval yeast with a single bud.
• in tissues it may appear as pseudohyphae or
yeasts.
• since Candida is part of normal human flora
it is not transmitted.
C. Albicans
Pathogenesis
• Most common opportunistic fungi.
• Causes thrush, vaginitis, chronic
mucocutaneous candidiasis
• When local or systemic host defenses are
impaired, disease may result.
Pathogenesis
• may disseminate to multiple organs esp. in
IVDA and right sided endocarditis.
• kidney is the most commonly involved
organ with systemic fungal infection. >85%
• Accounts for 6.9% of nosocomial infections
Pathogenesis
• Candida Spp are the most common
organisms causing fungal UTI.
• Candida albicans accounts for 74%
• Glabrata 8%
• Parapsolosis7%
• Tropicalis 3%
Predisposing Conditions
1)
2)
Diabetes (impaired phagocytic and
fungacidal function of neutrophils)
Protracted course of antibiotics
Predisposing Conditions
4)
5)
6)
7)
8)
Neoplasm
Oral contraceptives
Elderly Population
Infants- due to immature T-Cell
defense
Chronic indwelling catheter
Symptoms
• Frequency, dysuria and stranguria
• Pyuria , hematuria or pneumaturia
• classic findings of pyelonephritis,
fever, flank pain and CVAT
• high index of suspicion b/c fungal UTI
may present like bacterial UTI.
Diagnostic Features
• microscopic urine studies
• urine culture can be helpful for species
identification and sensitivities
• Urine colony counts (significant if
>105 without indwelling urinary
catheter)
Simple
vs.
Complex UTI
Simple UTI
• Confined to urinary bladder and urethra.
• Pt may present with cystitis.(2% of UTIs)
• Cystoscopy may present with white patches on
bladder wall.
• Bladder wall edema and erythema may be
present.
• Bladder infections can lead to rupture. (rare)
• Microscopic: Inflammatory cells, yeast forms
and pseudohyphae may be present
Treatment
• Bladder irrigation with Amphotericin B
50mg/1L water x10-14 d
• Effective in 80-92% of patients
• Nystatin and Miconazole useful. -poor
colloid dispersion in Nystatin-limits use
• Surgical intervention may be required in
the form of mucosal debridement
• Removal of large fungal bezoars if
present.
Complex UTI
• Complex infections affect the kidneys
and ureters
• Result of either hematogenous spread
or ascending from lower tract
infections
• Associated with fungal accretions that
may lead to obstructive uropathy.
Complex UTI
• May lead to persistent candiduria.
• High potential for disseminated
infection
• Approximately 88% present with fever
and flank pain
• 88% associated with hydronephrosis
• 81% associated with fungemia
Imaging
• U/S, Excretory urography,
• Retro pyelogram
• CT
• Renal Scintigraphy
Imaging studies typically exhibit filling
defects of the urinary system
Treatment
• Localized
Amphotericin B irrigation for infection of
the collecting system..
• Systemic or multifocal infection
IV Ampho B 6mg/kg (Gold Standard) ,
Fluconazole 100mg BID x 10 days
5-FC- 150mg/kg- high resistance
CASE
• HPI:56 year old male with 4 day history of
fever , N/V and diffuse abdominal pain. Anuria
24 hrs prior to admission to the hospital.
• PMH- Diabetes type II diagnosed 5 years prior,
controlled with insulin. UTI 6 months prior tx’d
with abx.
CASE
• Exam- pt. was febrile & appeared acutely
ill.
Dry mucous membranes
Diffusely tender abdomen
Bilateral CVAT
• LABS:
Leu =25x10^9 with 82% pmns
BUN 82, Creat 7.9 Glu 280
CASE
•
U/A: Numerous leukocytes per hpf
Many yeast forms.
• Pt was initially treated with Ampicillin
and Ciprofloxacin. IVF and IV insulin.
• Symptoms persisted.
CASE
•
U/S- bil. hydonephrosis
• Cystoscopy with RPG was unsuccessful
due to bilateral ureteral obstruction.
• Bilateral percutaneous nephrostomy
tubes were placed (turbid yellow/white
urine was recovered.
• Antegrade pyelogram- dilation of renal
pelvises and ureters. Multiple filling
defects.
CASE
•
Urine culture- C.Tropicalis 10^4 - 10^5
• Blood cultures on admission were
negative for fungi or bacteria.
• Treatment: IV Amphotericin B, direct
Ampho B through nephrostomies.
• Fragmentation of fungal balls by guide
wire manipulation.
CASE
• Therapy cont.for 3 weeks until U/C were
negative.
• Dc’d with Creatinine of 2.1mg/dL.
• No evidence of hydronephrosis at 6 month
follow up.
Cryptococosis
• Organism: Cryptococcus neoformans
• Properties: oval, budding yeast
• Epidemiology: Occurs widely in nature,
found in pigeon droppings
• Transmission: Inhalation of organism
• Clinical manifestations: Pulmonary
infection to virulent pneumonia &
meningitis.
Cryptococosis
• Predisposition: HIV, DM, lymphoma,
ETOH abuse
• GU involvement:
Adrenal-infarction
Renal- pyelonephritis,abscess
Prostate- bladder outlet obstruction or
prostatitis
Penis- ulcers of glans
Cryptococosis
• Tx: Adrenal-Amphotericin B
•
Renal- IV Amphotericin B
•
Prostate-Fluconazole 200-600mg/d
x 4 wks
•
Penis- Resection followed by
systemic Ampho B
Apergillosis
• Organism: A. fumigatus and A.Flavus
• Properties: Only mold form (V shaped
branches)
• Epidemiology: Widely distributed in nature.
Grow on decaying vegetables. Linked to
hospital construction and central air
conditioning .
• Transmission: Airborne conidia.
Apergillosis
• Predisposition: abraded skin, wounds,
cornea, ext. ear and sinuses,
immunocompromised
• GU involvement: Renal- DM,
malignancy or AIDS
(Fever, CVAT, obstructive uropathy)
Prostate and Genital-DM, Met colon ca,
steroid use & AIDS
• DX:Isolation from urine,semen or tissue.
Apergillosis-Treatment
• Systemic Amphotericin B for 3 months
Kidney-Percutaneous aspiration,
nephrostomy & J- stents
• Very little data to support use of
itraconazole
Environmental Fungi
Coccidioidomycosis
• Organism: Coccidioides immitus
• Properties:dimorphic exists as mold in
soil and spherule in tissue
• Location: Western U.S and Mexico.
Thrives in arid desert regions.
• Transmission: Airborne infection of the
pulmonary system
Coccidioidomycosis
• Clinical manifestations: mild influenza or flu
like illness Valley fever.
• Predisposition: Age >65 and HIV+
• Disseminated infection: less than 1% of
pulmonary infection become disseminated
• Men, pregnant women, immunocompromised
and non white persons more likely to have
disseminated infection
Coccidioidomycosis
• GU involvement:
• : kidney disease in 36-46% of persons with
disseminated disease-microbscess & granulomas
• prostate in 3-6%
• GU manifestations: Voiding dysfunction
Scrotal swelling
Hematuria
Pneumaturia
Histoplasmosis
• Organism: H. Encapsulatum
• Properties: dimorphic- mold in soil; yeast
in tissues
• Epidemiology: endemic in central and
eastern states, esp Mississippi and Ohio
grows in soil contaminated with bird
droppings and guano.
• Transmission and pathogenesis: Inhaled
spores are engulfed by macrophages and
develop into yeast forms.
Histoplasmosis
• Majority of involvement is spleen and
liver. Pulmonary involvement results in
cavitary lesions.
• Clinical manifestations: pneumonia
• Predisposition: HIV+, transplant pts &
children.
Histoplasmosis
• GU involvement:
• Kidneys- noncaseating
granulomas,cutaneous fistulas.
• Adrenal-Addison’s dz- will require hormone
replacement.
• Prostate- Abscesses
Histoplasmosis
• Dx- Identification of organism in
urine,semen or tissue. Culture or skin
test.
• Tx- IV Amphotericin B(>2g) total dose
followed by long term Itraconazole
200mg/d x12 wks
• Surgical management- Surgical excision
or drainage of prostate abscess.
Blastomyces
• Organism: Blastomyces dermatitidis
• Properties: Dimorphic, mold in soil,
yeast in tissue
• Broad-based budding
• Epidemiology: North and Central
America, also Africa. Grows in moist
soil.
Blastomyces
• Transmission: Inhalation of mold form.
Primarily affects lungs, skin, bone and
CNS
• Manifestations: flu-like illness, high
fever, respiratory illness that mimics TB
or Cancer
• Often subclinical infection.
• GU- prostate, epididymis, tubo-ovarian
abscess
Blastomyces
• Dx: Fungus in urine, semen or
• Detection of blastomyces A antigen by
immunodiffusion.
• Tx: Ketoconazole 400mg/d x 12mos for
prostate and epididymis involvement.
Amphotericin B for disseminated infxn
and immunocompromised
Rare Fungi
Mucormycosis
• Organism- Mucor
• Properties-mold
• Epidemiology-widely in nature
• Transmission- Inhalation of airborne
spores
• Predisposition- DKA,AIDS, liver
abnormalities
Mucormycosis
• Manifestations- primarily rhino cerebral,
sinusitis and brain hemorrhage
• GU- Primarily fever and flank pain
• Dx- biopsy showing mold with
nonseptate hyphae
• Tx-IV amphotericin B >1gram for 1
month
Rare Fungi
1)
2)
3)
4)
5)
6)
Geotrichum candidum
Paecilomyces
Paracoccidioides brasilensis
Penicillim glaucum
Penicillium citrinum
Trichosporon
Rare Fungi
7) Fusarium
8) Pseudallescheria boydii
9) Cunninghamella
10) Rhinosporidium seeberi
11) Sporothrix schenckii
Summary:
– The number of urinary tract infections
caused by fungi is increasing. Although the
majority of fungal UTIs are caused by
Candida species, physicians must maintain a
high index of suspicion in order to identify
the rare and environmental fungi that cause
disease.
Summary:
Many factors such as overuse of antibiotics,
immunosuppression , antifungal resistance and
disseminated fungal infections predispose
individuals to developing fungal UTI.
The astute physician must identify predisposing
medical conditions and anatomical defects; then
treat them accordingly.
Summary:
Before beginning antifungal therapy first
obtain a U/A (rule out contamination).
Urine and blood cultures should be
obtained in order to identify the organism
and sensitivities.( This helps to prevent
overuse of abx and avoids contrubuting to
the increasing amount of resistance
antifungal agents.)
Summary:
If obstruction or structural abnormalities
are suspected then imaging of the urinary
system is warranted.
If defects are visualized, only then should
surgical management be employed.