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234.e2 Cystitis, Fungal/Algal

Cystitis, Fungal/Algal Client Education
Sheet
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BASIC INFORMATION
• Secondary fungal/algal cystitis: depends on
culture media.
organism and organ distribution (pp. 81, ○ Many organisms grow readily on standard
Definition 121, and 223) ■ Candida spp (most common cause of
Rare infection of the urinary tract caused by funguria) and Prototheca spp grow on
fungal or algal organisms (most often Candida Etiology and Pathophysiology blood agar within 2-3 days.
sp). Infections can be primary (confined to • Primary fungal cystitis: disruption of urinary ■ Other fungal organisms may require
the urinary tract) or secondary (systemic or tract defense mechanisms permits ascending culture for longer periods.
disseminated infection with secondary shedding infection from genital mucosa or external ○ Speciation requires culture on specific
of organisms into the urine). environment. media (e.g., Sabouraud).
○ Pyelonephritis occurs when organisms • Antifungal drug susceptibility testing
Synonyms ascend from the bladder to the kidney. ○ Recommended for Candida spp infections
Candiduria, fungal urinary tract infection ○ Primary fungal cystitis reported with that do not respond to standard therapy
(UTI); funguria Aspergillus spp, Candida spp, Cryptococcus ○ Recommended for non–C. albicans
neoformans, Trichosporon sp, Rhodotorula candidal and noncandidal fungal infec-
Epidemiology sp tions because of increased likelihood of
SPECIES, AGE, SEX • Secondary fungal/algal cystitis: systemic resistance
Reported in dogs and cats. No age predisposi- infection with colonization of the kidneys ○ Recommended for Prototheca spp
tion but associated risk factors more common in results in urinary shedding of organisms. infections because of widely varying
older animals. Females possibly at increased risk ○ Fungal organisms isolated from urine in susceptibilities
dogs or cats with disseminated infections:
RISK FACTORS Acremonium sp, Aspergillus spp, Blastomyces TREATMENT
Diabetes mellitus, urinary tract stomata (e.g., dermatitidis, Candida spp, Cryptococcus
perineal urethrostomy), urinary tract catheter- neoformans, Paecilomyces spp, Penicillium Treatment Overview
ization, concurrent lower urinary tract disease spp, Phialemonium obovatum, Trichosporon Resolution of primary fungal cystitis usually
(e.g., neoplasia, recurrent bacterial cystitis), spp requires elimination or control of predisposing
prolonged antibiotic or immunosuppressive ○ Algal organisms isolated from urine conditions. Fluconazole is the recommended
drug administration in dogs with disseminated infections: first-line antifungal drug, but many infections
Prototheca spp recur.
CONTAGION AND ZOONOSIS
No zoonotic risk because organisms are DIAGNOSIS Acute General Treatment
ubiquitous in the environment. • Primary C. albicans infections: fluconazole
Diagnostic Overview 5-10 mg/kg PO q 12-24h for 4-6 weeks
ASSOCIATED DISORDERS Identification of fungal organisms within urine • Primary non–C. albicans candidal infections,
Fungal pyelonephritis, fungal granuloma, fungal sediment allows presumptive diagnosis of fungal other fungal agents, and secondary/systemic
septicemia, disseminated/systemic fungal or cystitis. Definitive diagnosis and organism fungal and algal infections: therapy based on
algal infection identification requires fungal urine culture. susceptibility testing
Identification of the infecting species is required ○ Primary infections: start fluconazole while
Clinical Presentation to predict whether infection is more likely to be waiting for susceptibility results.
DISEASE FORMS/SUBTYPES primary or secondary and for selecting initial ○ Secondary/systemic infections: start itra-
• Primary fungal cystitis: infection confined antifungal therapy. conazole while waiting for susceptibility
to bladder/lower urinary tract results.
• Fungal pyelonephritis: infection of renal Differential Diagnosis
pelvis and parenchyma, usually due to Differentials for fungal elements in urine sedi- Chronic Treatment
ascending lower UTI ment: contamination from genital mucosa or • Primary fungal infections should always be
• Secondary fungal/algal cystitis: urinary skin, primary fungal cystitis, secondary fungal treated as complicated UTIs:
shedding of organisms due to systemic/dis- cystitis ○ Reculture urine 1-2 weeks after starting
seminated infection with renal involvement therapy to assess efficacy.
Initial Database ○ Continue treatment until two successive
HISTORY, CHIEF COMPLAINT • CBC and biochemistry profile negative urine cultures 2-3 weeks apart
• Primary fungal cystitis may be asymptomatic, ○ Primary fungal cystitis: unremarkable • If infection does not respond or recurs, repeat
particularly in dogs and cats with diabetes ○ Fungal pyelonephritis: azotemia possible susceptibility testing. Comparative trials with
mellitus. ○ Disseminated infection: abnormalities other treatments have not been performed.
• Lower urinary tract disease signs (dysuria, depend on extent of infection and organs • Intravesicular clotrimazole infusion may be
pollakiuria, stranguria) are possible. involved attempted in dogs or cats with persistent
• Clinical signs secondary to acute kidney • Urinalysis infections despite treatment with fluconazole.
injury or chronic kidney disease may accom- ○ Organisms often seen on urine sediment ○ Place Foley catheter, empty bladder
pany fungal pyelonephritis or secondary examination or urine cytospin preparations ○ Infuse 7.5-10 mL/kg 1% clotrimazole
fungal/algal cystitis. ○ Pyuria and hematuria frequently absent solution. Volume should be determined
• Signs of other organ system dysfunction may by bladder palpation during infusion.
occur with secondary fungal/algal cystitis. Advanced or Confirmatory Testing ○ Solution should be retained for ≥ 30
• Urine culture minutes if possible.
PHYSICAL EXAM FINDINGS ○ Identification of fungal or algal organisms ○ Repeat q 1 week for 3-4 weeks.
• Primary fungal cystitis or pyelonephritis: in urine sediment should be followed by ○ Continue oral antifungal therapy during
usually unremarkable culture of cystocentesis-obtained urine. infusions.
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