What is the treatment for Candida glabrata in urine?

Treatment for Candida Glabrata in Urine

For fluconazole-resistant Candida glabrata in urine, amphotericin B deoxycholate at 0.3-0.6 mg/kg daily for 1-7 days OR oral flucytosine at 25 mg/kg 4 times daily for 7-10 days is recommended as first-line treatment. 1

Assessment and Initial Management

Before initiating treatment, consider these important factors:

1. Determine if treatment is necessary:

   • Treatment is NOT recommended for asymptomatic candiduria unless the patient belongs to a high-risk group 1, 2
   • High-risk groups requiring treatment include:
     • Neutropenic patients
     • Very low birth weight infants (<1500g)
     • Patients undergoing urologic manipulation
     • Patients with suspected disseminated infection

2. Remove predisposing factors:

   • Elimination of indwelling bladder catheters is strongly recommended whenever feasible 1
   • Removing catheters alone can resolve candiduria in approximately 50% of cases 2

3. Identify the organism and susceptibility:

   • Obtain urine culture to confirm Candida glabrata and determine antifungal susceptibility 2

Treatment Algorithm for Candida Glabrata UTI

For Symptomatic Cystitis:

1. First-line options (C. glabrata is typically fluconazole-resistant):

   • Amphotericin B deoxycholate: 0.3-0.6 mg/kg daily for 1-7 days 1
   • Oral flucytosine: 25 mg/kg 4 times daily for 7-10 days 1

2. Alternative/adjunctive options:

   • Amphotericin B deoxycholate bladder irrigation: 50 mg/L sterile water daily for 5 days 1
   • In transplant recipients with chronic symptomatic infection, micafungin 100-150 mg daily may be considered despite poor urinary concentrations 2, 3

For Pyelonephritis:

1. First-line options:

   • Amphotericin B deoxycholate: 0.3-0.6 mg/kg daily for 1-7 days with or without oral flucytosine 1
   • Oral flucytosine monotherapy: 25 mg/kg 4 times daily for 2 weeks (consider in select cases) 1

2. Additional measures:

   • Eliminate urinary tract obstruction (strongly recommended) 1
   • Remove or replace nephrostomy tubes/stents if present 1
   • Consider irrigation through nephrostomy tubes with amphotericin B deoxycholate (25-50 mg in 200-500 mL sterile water) 1

For Fungal Balls or Abscesses:

• Surgical intervention is strongly recommended 1
• Combine with appropriate antifungal therapy as noted above 1, 2

Special Considerations

1. Duration of therapy:

   • Typically 2 weeks for uncomplicated infections 1, 2
   • Continue until symptoms resolve and urine cultures become negative 2

2. Monitoring:

   • Follow-up urine cultures to confirm eradication 2
   • Monitor renal function, especially with amphotericin B due to nephrotoxicity risk 2

3. Cautions:

   • Newer azoles and echinocandins generally achieve poor urine concentrations and are not recommended for uncomplicated urinary tract infections 4
   • However, echinocandins may be considered when infection has invaded renal tissue rather than being limited to the collecting system 2, 5

4. For patients undergoing urologic procedures:

   • Prophylactic treatment with oral fluconazole 400 mg daily OR amphotericin B deoxycholate 0.3-0.6 mg/kg daily for several days before and after the procedure 1

Pitfalls to Avoid

1. Treating asymptomatic candiduria in patients without risk factors for dissemination - this is not recommended and may lead to unnecessary drug exposure and resistance 1, 2

2. Relying on echinocandins as first-line therapy for uncomplicated urinary tract infections due to their poor urinary concentrations 4

3. Failing to remove urinary catheters when feasible - catheter removal alone resolves many cases without antifungal therapy 1, 2

4. Overlooking the need for surgical intervention in cases with fungal balls or abscesses 1, 2