What is the recommended treatment for oral Candida glabrata infection?

Treatment of Oral Candida Glabrata Infection

For oral Candida glabrata infection, the recommended first-line treatment is oral fluconazole 100-200 mg daily for 7-14 days, with alternative options for fluconazole-refractory cases including amphotericin B deoxycholate oral suspension. 1

First-Line Treatment Options

Mild Disease

• Topical antifungal agents:
  • Clotrimazole troches, 10 mg 5 times daily for 7-14 days 1
  • Miconazole mucoadhesive buccal 50 mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days 1
  • Nystatin suspension (100,000 U/mL) 4-6 mL 4 times daily for 7-14 days 1
  • Nystatin pastilles (200,000 U each) 1-2 pastilles 4 times daily for 7-14 days 1

Moderate to Severe Disease

• Oral fluconazole, 100-200 mg daily, for 7-14 days 1

Management of Fluconazole-Refractory C. glabrata Infection

C. glabrata presents unique treatment challenges due to its reduced susceptibility to fluconazole and other azoles 1, 2. When oral C. glabrata infection is unresponsive to fluconazole, consider:

1. Amphotericin B deoxycholate oral suspension:

   • 25-50 mg in 200-500 mL sterile water 1
   • Swish and swallow or swish and spit, depending on clinical scenario

2. Topical options (adapted from vulvovaginal treatment recommendations):

   • Nystatin suspension at higher concentrations or frequency 1
   • Compounded boric acid preparations (for severe refractory cases) 1, 3

Special Considerations

Resistance Patterns

• C. glabrata often demonstrates reduced susceptibility to azoles, including fluconazole 2, 4
• Amphotericin B resistance is described in some C. glabrata isolates, though not universal 1
• Consider susceptibility testing for persistent infections 1

Risk Factors to Address

• Identify and manage underlying conditions that promote candidiasis:
  • Hyposalivation/xerostomia 5
  • Poor oral hygiene 5
  • Denture use (remove and clean dentures thoroughly) 5
  • Immunosuppression 5, 4
  • Diabetes mellitus 3

Treatment Duration

• Standard course: 7-14 days for uncomplicated cases 1
• Consider extended therapy for immunocompromised patients or persistent infections

Treatment Algorithm

1. Confirm diagnosis: Clinical examination plus fungal culture to identify C. glabrata
2. Assess severity:
   • Mild: Localized erythema, minimal symptoms
   • Moderate/Severe: Extensive erythema, pain, difficulty eating/swallowing
3. Initial treatment:
   • Mild: Topical antifungals (clotrimazole, nystatin)
   • Moderate/Severe: Fluconazole 100-200 mg daily for 7-14 days
4. For fluconazole-refractory cases:
   • Switch to amphotericin B deoxycholate oral suspension
   • Consider susceptibility testing
5. Supportive measures:
   • Address underlying risk factors
   • Maintain good oral hygiene
   • Avoid irritating foods and beverages

Monitoring and Follow-up

• Clinical assessment after 7-14 days of therapy
• Consider repeat culture for persistent symptoms
• Evaluate need for extended therapy in immunocompromised patients

Pitfalls and Caveats

• Do not rely on fluconazole alone for known C. glabrata infections due to frequent resistance 1, 2, 4
• Posaconazole may have activity against some fluconazole-resistant strains but should not be first-line therapy 6
• Echinocandins have limited utility for mucosal candidiasis despite activity against C. glabrata in systemic infections 7
• Avoid lipid formulations of amphotericin B for oral infections as they may not achieve adequate local concentrations 7