Fungal infection of urinary tract 신장내과 R4 최선영

Opportunistic fungal pathogen in urinary tract  Candida : most prevalent and pathogenic fungi UTI –hematogenous spread –ascending infection World J Urol 1999;17:

Diabetics –Impairment of the phagocytic and fungicidal activity of neutrophil –Female : higher vaginal and periurethral Candida colonization rate Antibiotics –Suppressing susceptible endogenous bacterial flora in the GI tract and lower genital tract

Renal candidiasis –Hematogenous spreading –Tropism for kidney –Autopsy study multiple abscess in the renal interstitium, glomeroli, peritubular vessels  papilary necrosis, rarely emphysematous pyelonephritis

Clinical features Majority of patients with candiduria : asymptomatic –Colonization > infection Clinical manifestation – site of infection –Candida cystitis signs and symptoms of bladder irritation (frequency, dysuria, urgency, hematuria, pyuria) Cystoscopy : pearly white, soft, slightly elevated patches, hyperemia and inflammation of the bladder mucosa

–Candida pyelonephritis Fever, leukocytosis, rigor, CVA tenderness US or CT scan : useful in diagnosing intrarenal or perinephric abscess Excretory urography : ureteropelvic fungal balls Ascending infection  candidemia : anatomic obstruction, manipulation, urologic procedure –Fungal bezoar (fungal ball) Anywhere but most commonly pelvis and upper ureter Signs of ureteral obstruction Excretory urography or retrograde pyelography : filling defect in the collecting system

–Renal candidiasis secondary to hematogenous spread Systemic infection : fever, other constitutional manifestation of sepsis, disseminated candidiasis (skin rash, endophthalmitis) Fever + candiduria

Diagnosis Isolation of Candida spp. From the urine sample –Contamination : colonization –Repetition of urine culture  antifungal therapy –Indwelling catheter : colonization vs infection Fever, leukocytosis, pyuria, fungal morphology, colony count –Noncatheterized patients Urinary count 10,000-15,000 CFU/mL urine

Localization of the source or anatomic level of infection –Indirect nonspecific evidence of upper tract infection declining renal function constitutional feature radiologic finding of US or CT scan 5-day bladder irrigation with amphotericin B  postirrigation candiduria

Management of candiduria Asymptomatic candiduria –No specific antifungal therapy –Indwelling catheterization Systemic or local antifungal therapy Relapse – frequent –Asymptomatic candiduria after renal transplantation –Persistent asymptomatic candiduria –Urologic instrumentation or surgery

Candida cystitis –Symptomatic : require treatment –amphotericin B bladder instillation (50  g/mL) –systemic therapy (IV amphotericin B, flucytosine, fluconazole) –Oral fluconazole : water-soluble, orally well absorbed, excreted unchanged in the urine to a high proportion of >80%

Ascending pyelonephritis and Candida urosepsis –Invasive upper tract infections : systemic antifungal therapy, visualization of the urinary drainage system –IV ampho B 0.6mg/kg/day (total dose 1-2g) –Fluconazole 5-10mg/kg/day (IV or orally) –Renal failure : fluconazole dose ￪ –Refractory to medical therapy : surgical drainage or nephrectomy (nonviable), PCN –Ureteral fungal ball Spontaneously lyse or dislodged during placement of ureteral stent Nephrostomy + local ampho B or fluconazole irrigation

Renal and disseminated candidiases –For systemic candidiasis IV ampho B 0.6mg/kg/day or fluconazole 400mg/day –Correction of underlying factors Systemic : 4-6 weeks duration