How do I manage candiduria: practical algorithms and remaining conundrums in 2026.

Abstract

Background: Candiduria is frequently encountered in hospitalized patients and encompasses a wide spectrum of clinical scenarios, ranging from asymptomatic colonization or sample contamination to genuine urinary tract infections and, in rarer cases, invasive candidiasis. Despite its high prevalence, especially in urological and intensive care settings, its clinical relevance is often uncertain, leading to diagnostic uncertainty and inconsistent management, even among infectious disease specialists.

Objectives: This review aims to provide a structured approach to the evaluation and management of candiduria, illustrated by a clinical vignette. The objective is to support evidence-informed decision-making by highlighting key diagnostic and therapeutic decisions.

Sources: In the absence of randomized controlled trials addressing symptomatic candiduria management, we conducted a narrative review of the literature, focusing on observational studies and expert guidance from the 2016 IDSA and 2025 international ECMM guidelines.

Content: Based on the case of a patient with a double-J ureteral stent presenting with acute febrile illness, this review explores diagnostic and therapeutic challenges associated with candiduria. It addresses epidemiology, risk factors, and the distinction between colonization and infection. Antifungal treatment options are discussed considering their pharmacological properties, particularly their diffusion in kidneys and excretion in urine and potential toxicities. We further address the rare but severe complication of fungus balls.

Implications: By converting current evidence into practical clinical algorithms, this review aims to enhance diagnostic accuracy, support antifungal stewardship, and highlight gaps in knowledge. It underscores the need for further research to improve evidence-based management strategies for candiduria.