What is the treatment for a positive urine culture showing Candida glabrata?

Treatment for Candida glabrata in Urine Culture

For a positive urine culture showing Candida glabrata, treatment with oral flucytosine 25 mg/kg four times daily for 7-10 days is recommended as the first-line therapy, with amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days as an alternative option. 1

Initial Assessment and Management

When treating candiduria with C. glabrata, consider these key factors:

• Determine if the patient is symptomatic or asymptomatic
• Evaluate for risk factors and underlying conditions
• Remove indwelling urinary catheters if present
• Correct any urinary tract obstruction

Symptomatic vs. Asymptomatic Candiduria

• Symptomatic patients: Require antifungal treatment
• Asymptomatic patients: Generally do not require treatment unless they belong to high-risk groups:
  • Neutropenic patients
  • Very low birth weight infants
  • Patients undergoing urologic procedures 1

Treatment Algorithm for C. glabrata Candiduria

First-line options:

1. Oral flucytosine: 25 mg/kg four times daily for 7-10 days 1
2. Amphotericin B deoxycholate: 0.3-0.6 mg/kg daily for 1-7 days 1

Alternative options:

• Amphotericin B bladder irrigation: 50 mg/L sterile water daily for 5 days (for localized bladder infections) 2, 1

Important considerations:

• Fluconazole is ineffective for C. glabrata due to intrinsic resistance 1
• Echinocandins (caspofungin, micafungin, anidulafungin) have minimal urinary excretion and are generally ineffective for UTIs despite activity against C. glabrata in bloodstream infections 1
• Lipid formulations of amphotericin B do not achieve adequate urine concentrations and should not be used 1

Duration of Treatment

• Treatment should continue until symptoms have resolved and urine cultures no longer yield Candida species 2, 1
• Typically 7-10 days for uncomplicated infections 1
• Follow-up urine cultures should be obtained to confirm eradication 1

Special Considerations

Catheterized Patients

• Removal of indwelling bladder catheters is strongly recommended whenever feasible 1
• Catheter removal alone resolves candiduria in almost 50% of asymptomatic patients 3

Renal Fungus Balls

• Require aggressive surgical debridement in addition to antifungal therapy 2
• Consider local irrigation with amphotericin B (50 mg/L sterile water) through percutaneous access as an adjunct to systemic therapy 2

Patients with Renal Impairment

• Dose adjustment may be required for flucytosine based on creatinine clearance 1
• Monitor for flucytosine toxicity, which can be frequent 2

Common Pitfalls to Avoid

1. Using fluconazole for C. glabrata: This species is inherently less susceptible to fluconazole compared to other Candida species 1

2. Using echinocandins or newer azoles: These agents fail to achieve adequate urine concentrations despite their activity against C. glabrata in bloodstream infections 3, 4

3. Treating all cases of candiduria: Most patients with asymptomatic candiduria are merely colonized and do not require antifungal therapy 3

4. Using lipid formulations of amphotericin B: These do not achieve adequate urine concentrations 1

5. Inadequate follow-up: Failure to obtain follow-up cultures to confirm eradication 1

By following this treatment approach for C. glabrata candiduria, focusing on appropriate antifungal selection and addressing underlying factors, you can effectively manage this condition while minimizing treatment failures and complications.