Philip J. Kozinn

Amphotericin B as a Urologic Irrigant in the management of Noninvasive Candiduria

High urinary colony counts of Candida may develop in patients with prolonged indwelling bladder catheters, multiple antibiotic usage and compromised host resistance. Serum candidal antibody titers may differentiate candidal colonization or early infection from invasive or disseminated infection. The persistence of marked candiduria in the absence of elevated antibody titers or other manifestations of disseminated infection presents a therapeutic dilemma to the urologist. Should the patient be treated with systemic therapy, that is flucytosine or intravenous amphotericin B, or should he be observed until the signs of systemic or renal infection develop? Amphotericin B may be used as a urological irrigant in the management of noninvasive urinary fungal infection. Of 40 patients with persistent candiduria treated with daily irrigations of amphotericin B via a 3-way indwelling urethral catheter or urethral catheter and suprapubic tube for an average of 6 days 37 (92.5 per cent) demonstrated marked reduction or elimination of the candiduria. None of the patients had an adverse reaction. Amphotericin B also has been used as a urological adjuvant to surgical treatment of candidal infection of the kidney and upper tract. It also has a role in the treatment in candidal urethritis. We believe that the timely use of amphotericin B irrigations may prevent the development of disseminated candidal infection.

Genitourinary candidiasis: diagnosis and treatment.

Candida in the urine or surgical wound is a potentially lethal pathogen. Management of 82 patients has provided a rationale for the treatment of these infections. Urine colony counts, serologic findings and clinical observations determine therapy. Amphotericin B irrigants are effective for local infections. Disseminated infections require flucytosine and/or intravenous amphotericin B.

Post mortem studies of systemic candidiasis: I. Diagnostic validity of precipitin reaction and probable origin of sensitization to cytoplasmic Candidal antigens

Precipitating antibodies against a cytoplasmic extract of Candida albicans (“S” antigen) were demonstrated during life in 14 of 17 patients who revealed systemic candidal infection Post mortem. No false positive precipitin reactions were observed. Three false negative reactions are attributed to terminal or disease-related anergy.The precipitin reaction proved diagnostically more reliable than mycologic evidence of infection. However, no diagnostic test at present available reflects adequately the extent and severity of the infection in a given case. Both were considerable in the present series, in whom on the average three internal organs were involved per patient.The macrophages of the reticuloendothelial system are implicated in the destruction of Candida and release of the cytoplasmic antigens that induce the precipitin response.The yeast phase of Candida appears to be the invasive form, and neither tubes nor mycelia seem to be essential in evoking the inflammatory or necrotic tissue changes that char...

Diagnosis and therapy of systemic candidiasis.

Systemic candidiasis is becoming a major obstacle in the care of debilitated patients, particularly those with primary or iatrogenically induced immune deficiencies. Successful management of this infection requires anticipatory surveillance of the potential victim, and correct interpretation of diagnostically significant signs and symptoms. Predisposing factors as well as clinical, mycological and serological findings that facilitate diagnosis are discussed in the light of 33 cases of systemic candidiasis observed by the authors.It is shown that timely treatment of candidemia raises the chances for survival from 20 to 80%. Toxic side and after effects of amphotericin B can be significantly minimized by holding the dosage to the minimum required to establish and maintain fungistatic serum levels of the drug and by judicious administration and spacing of the intravenous infusions. Guidelines for achieving these aims are presented.

Do the Imidazoles have a Role in the Management of Genitourinary Fungal Infections

The imidazoles have demonstrated antifungal activity against a number of fungi that are pathogenic for man. Effective clinical use has been demonstrated in patients with cutaneous and systemic candidiasis, aspergillosis, blastomycosis, coccidioidomycosis, cryptococcus and systemic candidiasis, aspergillosis, blastomycosis, coccidioidomycosis, cryptococcus and histoplasmosis. We report our experience with the oral imidazole agent ketoconazole in the management of 8 patients with significant urinary candidiasis as judged by elevated urinary candidal counts (greater than 15,000/ml.). Only 4 of the 8 patients had resolution of candiduria with ketoconazole therapy. Intravenous miconazole, another imidazole, has been available for treatment of systemic and genitourinary fungal infections. Limited success (50 per cent) with intravenous miconazole has been noted in the treatment of systemic candidiasis with urinary involvement. Miconazole also has been used as a systemic and local irrigant in the treatment of bladder and renal candidiasis. Based on these observations and our own studies, we believe that the imidazoles have a limited role in the management of patients with significant fungal involvement of the urinary tract.

Flucytosine in urinary candida infections.

Abstract Flucytosine (Ancobon), a chlorinated pyrimidine, was used in the treatment of 30patients with serious Candida infections of the urinary tract. Criteria for treatment included Candida counts greater than 10,000 colonies per milliliter; elevated serum antibody titers against Candida antigen, and lack of response to local antifungal therapy. Twenty-three of 30 patients (77 per cent): responded to treatment. Side effects were few and limited to reversible changes in liver function and bone marrow. Flucytosine given orally provides the physician with a new treatment for significant Candida infections.

Agranulocytosis associated with flucytosine for urinary candidiasis

Abstract A case of urinary candidiasis is reported in which one adverse reaction occurred with flucytosine therapy. Despite this adverse effect, the authors point out that their total clinical experience with this therapy has been rewarding.