What is the recommended treatment for Candida glabrata (C. glabrata) infection?

Treatment of Candida glabrata Infections

For fluconazole-resistant C. glabrata infections, amphotericin B deoxycholate (0.3-0.6 mg/kg daily for 1-7 days) or oral flucytosine (25 mg/kg 4 times daily for 7-10 days) is the recommended treatment. 1

Treatment Recommendations by Infection Site

Urinary Tract Infections

• Fluconazole-resistant C. glabrata cystitis:
  • Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1
  • OR oral flucytosine 25 mg/kg 4 times daily for 7-10 days 1
  • Removal of indwelling bladder catheter if feasible (strongly recommended) 1
  • Consider amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) for resistant cases 1

Pyelonephritis/Upper UTI

• Fluconazole-resistant C. glabrata:
  • Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days with or without flucytosine 1
  • Alternative: monotherapy with oral flucytosine 25 mg/kg 4 times daily for 2 weeks 1
  • Elimination of urinary tract obstruction is strongly recommended 1
  • Consider removal/replacement of nephrostomy tubes or stents if present 1

Vaginal Infections

• First-line: Topical intravaginal boric acid 600 mg daily for 14 days 2
• Alternatives:
  • Nystatin suppositories 100,000 units daily for 14 days 2
  • Topical 17% flucytosine cream daily for 14 days (alone or with 3% AmB cream) 2

Bloodstream Infections/Candidemia

• First-line: Echinocandins (caspofungin: 70-mg loading dose followed by 50 mg/day) 1
• Alternatives:
  • Amphotericin B deoxycholate 0.7 mg/kg/day 1
  • High-dose fluconazole (12 mg/kg/day; 800 mg/day for a 70-kg patient) may be considered for less critically ill patients 1
• Step-down therapy: Fluconazole can be used as step-down therapy after initial echinocandin treatment if the isolate is susceptible 3

Special Considerations

Azole Resistance

• C. glabrata often has reduced susceptibility to azoles 1
• Prior fluconazole use significantly increases risk of developing infection with fluconazole-resistant C. glabrata (OR 12.24) 4
• Other risk factors for fluconazole-resistant C. glabrata include diabetes and presence of central venous catheters 4

Treatment Duration

• For candidemia: minimum 14 days of therapy after documented clearance of Candida from the bloodstream
• For urinary tract infections: 7-14 days depending on severity and presence of complicating factors

Treatment Failures

• For patients failing initial therapy, consider:
  • Source control (catheter removal, abscess drainage)
  • Alternative antifungal agents
  • Susceptibility testing to guide therapy

Monitoring and Follow-up

• No routine follow-up needed if symptoms resolve 2
• Reevaluation necessary if symptoms persist despite adequate treatment 2
• For persistent symptoms, consider alternative diagnoses or need for culture confirmation 2

Common Pitfalls

1. Treating asymptomatic colonization (e.g., positive rectal swab without symptoms) is not recommended 2
2. Using fluconazole as empiric therapy for suspected C. glabrata without susceptibility testing can lead to treatment failure
3. Inadequate source control (failing to remove catheters or drain abscesses)
4. Insufficient treatment duration
5. Overlooking the need for higher fluconazole doses (12 mg/kg/day) when this agent is used for susceptible isolates

Remember that C. glabrata is the second most common species causing invasive candidiasis, and its reduced susceptibility to azoles necessitates careful selection of antifungal therapy to ensure optimal outcomes.