Candiduria in catheterized ICU patients: epidemiology, molecular identification, and antifungal susceptibility
,
Abstract
Background and Objectives: Candiduria related to urinary catheters is frequently encountered in patients hospitalized in intensive care units. The diagnosis and management of catheter-associated candiduria in hospitalized patients is frequently a gray area for both physicians and microbiologists because of the paucity of clinical and microbiological data.
Materials and Methods: This cross-sectional study aims to enhance the understanding of candiduria among adult ICU patients with urinary catheters across three hospitals in Tehran, Iran. Yeast identification was performed using a two-step multiplex PCR, and antifungal susceptibility testing was performed following the CLSI M27, 4th edition,
recommendations.
Results: Among the 110 enrolled ICU patients, 38 (35%) had significant candiduria. A total of 45 yeast isolates were collected. The distribution was as follows: Candida glabrata (23/45; 51%), C. albicans (14/45; 31%), and C. tropicalis (4/45; 9%). These three species accounted for 91% of the isolates. Antifungal resistance was detected: six isolates (two C. glabrata, two C. albicans, one C. krusei, and one C. tropicalis) were fluconazole-resistant, and one C. glabrata isolate was resistant to itraconazole, voriconazole, and caspofungin. All isolated species were susceptible to amphotericin B. Symptomatic candiduria occurred in 29% of cases (11/38); only 55% (6/11) were treated, and of those, 50% (3/6) experienced fluconazole treatment failure. One symptomatic patient developed candidemia shortly after acquiring candiduria. The mortality rate was 21% (8/38), with no apparent difference in death rates between symptomatic and asymptomatic candiduric patients.
Conclusion: Our findings reveal that high fluconazole failure rates among patients with symptomatic candiduria are concerning. Furthermore, speciation and antifungal susceptibility testing are crucial, as they guide clinicians in selecting the most effective agent and improving case management.
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3. Fang W, Wu J, Cheng M, Zhu X, Du M, Chen C, et al. Diagnosis of invasive fungal infections: challenges and recent developments. J Biomed Sci 2023; 30:42.
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10. Hollenbach E. To treat or not to treat–critically ill patients with candiduria. Mycoses 2008; 51:12-24.
11. Alfouzan WA, Dhar R. Candiduria: Evidence-based approach to management, are we there yet? J Mycol Med 2017; 27:293-302.
12. Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62(4):e1-50.
13. Jacobs DM, Dilworth TJ, Beyda ND, Casapao AM, Bowers DR. Overtreatment of Asymptomatic Candiduria among Hospitalized Patients: a Multi-institutional Study. Antimicrob Agents Chemother 2017; 62(1):e01464-17.
14. Kauffman CA. Candiduria. Clin Infect Dis 2005; 41 Suppl 6:S371-6.
15. Arastehfar A, Fang W, Pan W, Lackner M, Liao W, Badiee P, et al. YEAST PANEL multiplex PCR for identification of clinically important yeast species: stepwise diagnostic strategy, useful for developing countries. Diagn Microbiol Infect Dis 2019; 93:112-119.
16. Kord M, Elmimoghaddam A, Hashemi SJ, Reziae S, Daie Ghazvini R, Salehi M, et al. Comparison of PCR-RFLP with 21-plex PCR and rDNA Sequencing for Identification of clinical yeast isolates. Mycopathologia 2021; 186:213-220.
17. Clinical and Laboratory Standards Institute (2017). Reference method for broth dilution antifungal susceptibility testing of yeasts. M27. 4th ed. Clinical and Laboratory Standards Institute. Wayne, PA, USA.
18. Pfaller MA, Diekema DJ. Progress in antifungal susceptibility testing of Candida spp. by use of Clinical and Laboratory Standards Institute broth microdilution methods, 2010 to 2012. J Clin Microbiol 2012; 50:2846-2856.
19. Fisher JF, Sobel JD, Kauffman CA, Newman CA. Candida urinary tract infections--treatment. Clin Infect Dis 2011; 52 Suppl 6:S457-66.
20. Behzadi P, Behzadi E, Ranjbar R. Urinary tract infections and Candida albicans. Cent European J Urol 2015; 68:96-101.
21. Passos XS, Sales WS, Maciel PJ, Costa CR, Miranda KC, Lemos Jde A, et al. Candida colonization in intensive care unit patients' urine. Mem Inst Oswaldo Cruz 2005; 100:925-928.
22. Rathor N, Khillan V, Sarin SK. Nosocomial candiduria in chronic liver disease patients at a hepatobilliary center. Indian J Crit Care Med 2014; 18:234-237.
23. Pemán J, Ruiz-Gaitán A. Candidemia from urinary tract source: the challenge of candiduria. Hosp Pract (1995) 2018; 46:243-245.
24. Bouza E, San Juan R, Muñoz P, Voss A, Kluytmans J, Co-operative Group of the European Study Group on Nosocomial Infections. A European perspective on nosocomial urinary tract infections I. Report on the microbiology workload, etiology and antimicrobial susceptibility (ESGNI-003 study). European Study Group on nosocomial infections. Clin Microbiol Infect 2001; 7:523-531.
25. Simpson C, Blitz S, Shafran SD. The effect of current management on morbidity and mortality in hospitalised adults with funguria. J Infect 2004; 49:248-252.
26. Kauffman CA, Vazquez JA, Sobel JD, Gallis HA, McKinsey DS, Karchmer AW, et al. Prospective multicenter surveillance study of funguria in hospitalized patients. The National Institute for Allergy and Infectious Diseases (NIAID) Mycoses Study Group. Clin Infect Dis 2000; 30:14-18.
27. Safdar N, Slattery WR, Knasinski V, Gangnon RE, Li Z, Pirsch JD, et al. Predictors and outcomes of candiduria in renal transplant recipients. Clin Infect Dis 2005; 40:1413-1421.
28. Bougnoux ME, Kac G, Aegerter P, d'Enfert C, Fagon JY, CandiRea Study Group. Candidemia and candiduria in critically ill patients admitted to intensive care units in France: incidence, molecular diversity, management and outcome. Intensive Care Med 2008; 34:292-299.
29. Lockhart SR, Etienne KA, Vallabhaneni S, Farooqi J, Chowdhary A, Govender NP, et al. Simultaneous emergence of multidrug-resistant Candida auris on 3 continents confirmed by whole-Genome sequencing and epidemiological analyses. Clin Infect Dis 2017; 64:134-140.
30. Ruiz-Gaitán A, Moret AM, Tasias-Pitarch M, Aleixandre-López AI, Martínez-Morel H, Calabuig E, et al. An outbreak due to Candida auris with prolonged colonisation and candidaemia in a tertiary care European hospital. Mycoses 2018; 61:498-505.
31. Ahmadi F, Ghazvini RD, Hashemi SJ, Ramezanalipour Z, Chabavizadeh J, Rafat Z, et al. Epidemiologic and antifungal susceptibility profile of Candiduria among patients Hospitalized in the Nephrology and Intensive Care Unit Wards, Tehran, Iran. Jundishapur J Microbiol 2022; 15(5):e126418.
32. Gisi U. Crossover between the control of fungal pathogens in medicine and the wider environment, and the threat of antifungal resistance. Plant Pathol 2022; 71:131-149.
33. Farahnejad Z, Ghazanfari T, Yaraee R. Immunomodulatory effects of Aloe vera and its fractions on response of macrophages against Candida albicans. Immunopharmacol Immunotoxicol 2011; 33:676-681.
34. Singla N, Gulati N, Kaistha N, Chander J. Candida colonization in urine samples of ICU patients: determination of etiology, antifungal susceptibility testing and evaluation of associated risk factors. Mycopathologia 2012; 174:149-155.
35. Bayraktar S, Duran N, Duran GG, Eryilmaz N, Aslan H, Önlen C, et al. Identification of medically important Candida species by polymerase chain reaction-restriction fragment length polymorphism analysis of the rDNA ITS1 and ITS2 regions. Indian J Med Microbiol 2017; 35:535-542.
36. Pfaller MA, Diekema DJ, Turnidge JD, Castanheira M, Jones RN. Twenty Years of the SENTRY Antifungal Surveillance Program: Results for Candida Species From 1997-2016. Open Forum Infect Dis 2019; 6(Suppl 1):S79-S94.
37. Arastehfar A, Wickes BL, Ilkit M, Pincus DH, Daneshnia F, Pan W, et al. Identification of Mycoses in Developing Countries. J Fungi (Basel) 2019; 5:90.
38. Arastehfar A, Daneshnia F, Salehi M, Yaşar M, Hoşbul T, Ilkit M, et al. Low level of antifungal resistance of Candida glabrata blood isolates in Turkey: Fluconazole minimum inhibitory concentration and FKS mutations can predict therapeutic failure. Mycoses 2020; 63:911-920.
39. Sobel JD, Kauffman CA, McKinsey D, Zervos M, Vazquez JA, Karchmer AW, et al. Candiduria: a randomized, double-blind study of treatment with fluconazole and placebo. The National Institute of Allergy and Infectious Diseases (NIAID) Mycoses Study Group. Clin Infect Dis 2000; 30:19-24.
40. Gajdács M, Dóczi I, Ábrók M, Lázár A, Burián K. Epidemiology of candiduria and Candida urinary tract infections in inpatients and outpatients: results from a 10-year retrospective survey. Cent European J Urol 2019; 72:209-214.
41. Sobel JD, Bradshaw SK, Lipka CJ, Kartsonis NA. Caspofungin in the treatment of symptomatic candiduria. Clin Infect Dis 2007; 44(5):e46-9.
42. Huang PY, Hung MH, Shie SS, Su LH, Chen KY, Ye JJ, et al. Molecular concordance of concurrent Candida albicans candidemia and candiduria. Diagn Microbiol Infect Dis 2013; 76:382-384.
2. Terrero-Salcedo D, Powers-Fletcher MV. Updates in Laboratory Diagnostics for Invasive Fungal Infections. J Clin Microbiol 2020; 58(6):e01487-19.
3. Fang W, Wu J, Cheng M, Zhu X, Du M, Chen C, et al. Diagnosis of invasive fungal infections: challenges and recent developments. J Biomed Sci 2023; 30:42.
4. Leblebicioglu H, Ersoz G, Rosenthal VD, Yalcin AN, Akan OA, Sirmatel F, et al. Impact of a multidimensional infection control approach on catheter-associated urinary tract infection rates in adult intensive care units in 10 cities of Turkey: International Nosocomial Infection Control Consortium findings (INICC). Am J Infect Control 2013; 41:885-891.
5. Burton DC, Edwards JR, Srinivasan A, Fridkin SK, Gould CV. Trends in catheter-associated urinary tract infections in adult intensive care units-United States, 1990-2007. Infect Control Hosp Epidemiol 2011; 32:748-756.
6. Padawer D, Pastukh N, Nitzan O, Labay K, Aharon I, Brodsky D, et al. Catheter-associated candiduria: Risk factors, medical interventions, and antifungal susceptibility. Am J Infect Control 2015; 43(7):e19-22.
7. Gharaghani M, Taghipour S, Halvaeezadeh M, Mahmoudabadi AZ. Candiduria; a review article with specific data from Iran. Turk J Urol 2018; 44:445-452.
8. Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN) Patient Safety Component Manual. Natl Healthc Saf Netw Patient Saf Compon Man. 2024;1-39.
9. Aghili SR, Abastabar M, Soleimani A, Haghani I, Azizi S. High prevalence of asymptomatic nosocomial candiduria due to Candida glabrata among hospitalized patients with heart failure: a matter of some concern? Curr Med Mycol 2020; 6:1-8.
10. Hollenbach E. To treat or not to treat–critically ill patients with candiduria. Mycoses 2008; 51:12-24.
11. Alfouzan WA, Dhar R. Candiduria: Evidence-based approach to management, are we there yet? J Mycol Med 2017; 27:293-302.
12. Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62(4):e1-50.
13. Jacobs DM, Dilworth TJ, Beyda ND, Casapao AM, Bowers DR. Overtreatment of Asymptomatic Candiduria among Hospitalized Patients: a Multi-institutional Study. Antimicrob Agents Chemother 2017; 62(1):e01464-17.
14. Kauffman CA. Candiduria. Clin Infect Dis 2005; 41 Suppl 6:S371-6.
15. Arastehfar A, Fang W, Pan W, Lackner M, Liao W, Badiee P, et al. YEAST PANEL multiplex PCR for identification of clinically important yeast species: stepwise diagnostic strategy, useful for developing countries. Diagn Microbiol Infect Dis 2019; 93:112-119.
16. Kord M, Elmimoghaddam A, Hashemi SJ, Reziae S, Daie Ghazvini R, Salehi M, et al. Comparison of PCR-RFLP with 21-plex PCR and rDNA Sequencing for Identification of clinical yeast isolates. Mycopathologia 2021; 186:213-220.
17. Clinical and Laboratory Standards Institute (2017). Reference method for broth dilution antifungal susceptibility testing of yeasts. M27. 4th ed. Clinical and Laboratory Standards Institute. Wayne, PA, USA.
18. Pfaller MA, Diekema DJ. Progress in antifungal susceptibility testing of Candida spp. by use of Clinical and Laboratory Standards Institute broth microdilution methods, 2010 to 2012. J Clin Microbiol 2012; 50:2846-2856.
19. Fisher JF, Sobel JD, Kauffman CA, Newman CA. Candida urinary tract infections--treatment. Clin Infect Dis 2011; 52 Suppl 6:S457-66.
20. Behzadi P, Behzadi E, Ranjbar R. Urinary tract infections and Candida albicans. Cent European J Urol 2015; 68:96-101.
21. Passos XS, Sales WS, Maciel PJ, Costa CR, Miranda KC, Lemos Jde A, et al. Candida colonization in intensive care unit patients' urine. Mem Inst Oswaldo Cruz 2005; 100:925-928.
22. Rathor N, Khillan V, Sarin SK. Nosocomial candiduria in chronic liver disease patients at a hepatobilliary center. Indian J Crit Care Med 2014; 18:234-237.
23. Pemán J, Ruiz-Gaitán A. Candidemia from urinary tract source: the challenge of candiduria. Hosp Pract (1995) 2018; 46:243-245.
24. Bouza E, San Juan R, Muñoz P, Voss A, Kluytmans J, Co-operative Group of the European Study Group on Nosocomial Infections. A European perspective on nosocomial urinary tract infections I. Report on the microbiology workload, etiology and antimicrobial susceptibility (ESGNI-003 study). European Study Group on nosocomial infections. Clin Microbiol Infect 2001; 7:523-531.
25. Simpson C, Blitz S, Shafran SD. The effect of current management on morbidity and mortality in hospitalised adults with funguria. J Infect 2004; 49:248-252.
26. Kauffman CA, Vazquez JA, Sobel JD, Gallis HA, McKinsey DS, Karchmer AW, et al. Prospective multicenter surveillance study of funguria in hospitalized patients. The National Institute for Allergy and Infectious Diseases (NIAID) Mycoses Study Group. Clin Infect Dis 2000; 30:14-18.
27. Safdar N, Slattery WR, Knasinski V, Gangnon RE, Li Z, Pirsch JD, et al. Predictors and outcomes of candiduria in renal transplant recipients. Clin Infect Dis 2005; 40:1413-1421.
28. Bougnoux ME, Kac G, Aegerter P, d'Enfert C, Fagon JY, CandiRea Study Group. Candidemia and candiduria in critically ill patients admitted to intensive care units in France: incidence, molecular diversity, management and outcome. Intensive Care Med 2008; 34:292-299.
29. Lockhart SR, Etienne KA, Vallabhaneni S, Farooqi J, Chowdhary A, Govender NP, et al. Simultaneous emergence of multidrug-resistant Candida auris on 3 continents confirmed by whole-Genome sequencing and epidemiological analyses. Clin Infect Dis 2017; 64:134-140.
30. Ruiz-Gaitán A, Moret AM, Tasias-Pitarch M, Aleixandre-López AI, Martínez-Morel H, Calabuig E, et al. An outbreak due to Candida auris with prolonged colonisation and candidaemia in a tertiary care European hospital. Mycoses 2018; 61:498-505.
31. Ahmadi F, Ghazvini RD, Hashemi SJ, Ramezanalipour Z, Chabavizadeh J, Rafat Z, et al. Epidemiologic and antifungal susceptibility profile of Candiduria among patients Hospitalized in the Nephrology and Intensive Care Unit Wards, Tehran, Iran. Jundishapur J Microbiol 2022; 15(5):e126418.
32. Gisi U. Crossover between the control of fungal pathogens in medicine and the wider environment, and the threat of antifungal resistance. Plant Pathol 2022; 71:131-149.
33. Farahnejad Z, Ghazanfari T, Yaraee R. Immunomodulatory effects of Aloe vera and its fractions on response of macrophages against Candida albicans. Immunopharmacol Immunotoxicol 2011; 33:676-681.
34. Singla N, Gulati N, Kaistha N, Chander J. Candida colonization in urine samples of ICU patients: determination of etiology, antifungal susceptibility testing and evaluation of associated risk factors. Mycopathologia 2012; 174:149-155.
35. Bayraktar S, Duran N, Duran GG, Eryilmaz N, Aslan H, Önlen C, et al. Identification of medically important Candida species by polymerase chain reaction-restriction fragment length polymorphism analysis of the rDNA ITS1 and ITS2 regions. Indian J Med Microbiol 2017; 35:535-542.
36. Pfaller MA, Diekema DJ, Turnidge JD, Castanheira M, Jones RN. Twenty Years of the SENTRY Antifungal Surveillance Program: Results for Candida Species From 1997-2016. Open Forum Infect Dis 2019; 6(Suppl 1):S79-S94.
37. Arastehfar A, Wickes BL, Ilkit M, Pincus DH, Daneshnia F, Pan W, et al. Identification of Mycoses in Developing Countries. J Fungi (Basel) 2019; 5:90.
38. Arastehfar A, Daneshnia F, Salehi M, Yaşar M, Hoşbul T, Ilkit M, et al. Low level of antifungal resistance of Candida glabrata blood isolates in Turkey: Fluconazole minimum inhibitory concentration and FKS mutations can predict therapeutic failure. Mycoses 2020; 63:911-920.
39. Sobel JD, Kauffman CA, McKinsey D, Zervos M, Vazquez JA, Karchmer AW, et al. Candiduria: a randomized, double-blind study of treatment with fluconazole and placebo. The National Institute of Allergy and Infectious Diseases (NIAID) Mycoses Study Group. Clin Infect Dis 2000; 30:19-24.
40. Gajdács M, Dóczi I, Ábrók M, Lázár A, Burián K. Epidemiology of candiduria and Candida urinary tract infections in inpatients and outpatients: results from a 10-year retrospective survey. Cent European J Urol 2019; 72:209-214.
41. Sobel JD, Bradshaw SK, Lipka CJ, Kartsonis NA. Caspofungin in the treatment of symptomatic candiduria. Clin Infect Dis 2007; 44(5):e46-9.
42. Huang PY, Hung MH, Shie SS, Su LH, Chen KY, Ye JJ, et al. Molecular concordance of concurrent Candida albicans candidemia and candiduria. Diagn Microbiol Infect Dis 2013; 76:382-384.
| Files | ||
| Issue | Vol 18 No 1 (2026) | |
| Section | Original Article(s) | |
| DOI | https://doi.org/10.18502/ijm.v18i1.20939 | |
| Keywords | ||
| Candida Urinary catheters Drug resistance Intensive care unit | ||
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How to Cite
1.
Ahmadi A, Hazrati E, Noorifard M, Farahnejad Z, Mohammadimehr M. Candiduria in catheterized ICU patients: epidemiology, molecular identification, and antifungal susceptibility. Iran J Microbiol. 2026;18(1):138-146.
