Treatment of Candida glabrata Infections
Echinocandins are the recommended first-line treatment for Candida glabrata infections due to their superior efficacy compared to azoles. 1
First-Line Treatment Options
Echinocandins are strongly preferred for C. glabrata infections because:
- They demonstrate superior efficacy against C. glabrata compared to azoles
- They provide more reliable fungicidal activity in this setting
Specific echinocandin options include:
- Caspofungin: 70-mg loading dose, then 50 mg daily 1
- Anidulafungin: 200-mg loading dose, then 100 mg daily 1
- Micafungin: 100 mg daily 1, 2
Studies have shown that micafungin at 100 mg/day results in similar outcomes to other antifungal agents for C. glabrata infections, making this an acceptable option 2.
Alternative Treatment Options
When echinocandins cannot be used, alternative options include:
- Lipid formulation of amphotericin B: 3-5 mg/kg daily 1
- Amphotericin B deoxycholate: 0.5-1.0 mg/kg daily, though this is less preferred due to toxicity concerns 3, 1
For fluconazole-resistant C. glabrata urinary tract infections specifically:
- Amphotericin B deoxycholate: 0.3-0.6 mg/kg daily for 1-7 days 1
- Flucytosine: 25 mg/kg 4 times daily for 7-10 days (for cystitis) 1
- Amphotericin B bladder irrigation: 50 mg/L sterile water daily for 5 days (for cystitis) 1
Treatment Duration and Monitoring
- Treatment should continue for at least 2 weeks after documented clearance of Candida from the bloodstream and resolution of symptoms 1
- Follow-up blood cultures should be performed daily or every other day to establish clearance of candidemia 1
- For non-neutropenic patients with candidemia, intravenous catheter removal is strongly recommended 1
Susceptibility Testing
- Testing for azole susceptibility is strongly recommended for all bloodstream and clinically relevant C. glabrata isolates 1
- Testing for echinocandin susceptibility should be considered in patients with prior echinocandin exposure 1
Special Considerations for Neutropenic Patients
In neutropenic patients, higher doses of echinocandins may be required to achieve fungicidal effects 4. The standard doses may only achieve fungistatic effects in these patients, which could lead to treatment failure.
Combination Therapy
For severe or refractory C. glabrata infections, combination therapy may be considered:
- Liposomal amphotericin B with an echinocandin (caspofungin or micafungin) has shown improved outcomes in experimental models 5
Transitioning Treatment
- Transition from an echinocandin to fluconazole or voriconazole should only occur after confirmation of isolate susceptibility 1
- Higher-dose fluconazole (800 mg daily) may be considered for step-down therapy in susceptible isolates 1
- Voriconazole may be used as step-down oral therapy for voriconazole-susceptible C. glabrata 1
Potential Adverse Effects
- Echinocandins: Monitor for elevated liver enzymes and histamine-mediated reactions 6
- Amphotericin B: Monitor for nephrotoxicity and infusion-related reactions 1, 7
By following these evidence-based recommendations, clinicians can optimize treatment outcomes for patients with C. glabrata infections while minimizing adverse effects.