What is the recommended treatment for rectal Candida glabrata infection?

Treatment of Rectal Candida glabrata Infection

For rectal Candida glabrata infection, an echinocandin (caspofungin, micafungin, or anidulafungin) is the preferred initial treatment due to C. glabrata's inherent resistance to fluconazole. 1

Treatment Algorithm

First-line therapy:

• Echinocandin options:
  • Caspofungin: Loading dose of 70 mg, then 50 mg daily
  • Micafungin: 100 mg daily
  • Anidulafungin: Loading dose of 200 mg, then 100 mg daily 1

Alternative therapies (if echinocandins are unavailable or contraindicated):

1. Amphotericin B deoxycholate: 0.3-0.6 mg/kg daily for 1-7 days 1
2. Oral flucytosine: 25 mg/kg 4 times daily for 7-10 days 1
3. Combination therapy: Amphotericin B deoxycholate with oral flucytosine 1

Treatment Duration

• Continue treatment for 14 days after documented clearance of Candida species and resolution of symptoms 1

Important Considerations

Susceptibility Testing

• Perform antifungal susceptibility testing against fluconazole for C. glabrata isolates from sterile sites 1
• Do not transition to fluconazole or voriconazole without confirmation of isolate susceptibility 1

Monitoring and Follow-up

• Monitor for clinical response within 4-5 days of initiating therapy 1
• If no improvement after 72 hours of appropriate therapy, reevaluate and consider alternative treatments

Predisposing Factors

• Eliminate predisposing factors whenever feasible (e.g., immunosuppression, broad-spectrum antibiotics) 1
• For patients with indwelling devices, consider removal or replacement if feasible 1

Special Considerations

Fluconazole Resistance

C. glabrata has intrinsic reduced susceptibility to azoles, particularly fluconazole. Studies show that echinocandins are more effective for C. glabrata infections compared to fluconazole, with higher rates of clinical response 2.

Potential Step-down Therapy

If susceptibility testing confirms sensitivity to fluconazole and the patient has clinically improved, a transition to oral therapy might be considered for completion of the treatment course. However, this should only be done after confirming susceptibility 1, 3.

Rationale for Recommendation

The preference for echinocandins as first-line therapy is based on:

1. C. glabrata's inherent resistance to azoles, particularly fluconazole
2. Higher clinical response rates with echinocandins compared to fluconazole
3. Strong recommendations from the Infectious Diseases Society of America guidelines specifically for C. glabrata infections 1

Amphotericin B and flucytosine remain important alternative options, particularly in settings where echinocandins may not be available or are contraindicated 1.