What is the recommended treatment for a 78-year-old woman with Candida glabrata infection?

Treatment of Candida glabrata Infection in a 78-Year-Old Woman

For a 78-year-old woman with Candida glabrata infection, an echinocandin (caspofungin, micafungin, or anidulafungin) is strongly recommended as first-line therapy due to superior efficacy against this species. 1

First-Line Treatment Options

Echinocandins (Preferred)

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

Alternative First-Line Option

• Lipid formulation of amphotericin B: 3-5 mg/kg daily (less preferred due to potential toxicity, especially in elderly patients) 1, 2

Treatment Considerations Based on Infection Site

For Candidemia/Invasive Candidiasis

• Continue treatment 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 1
• Remove intravenous catheters if present 3

For Urinary Tract Infections

• Cystitis: For fluconazole-resistant C. glabrata, use 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) 3
• Pyelonephritis: For fluconazole-resistant C. glabrata, use amphotericin B deoxycholate (0.3-0.6 mg/kg daily for 1-7 days) with or without oral flucytosine 3
• Consider amphotericin B deoxycholate bladder irrigation (50 mg/L sterile water daily for 5 days) for cystitis due to fluconazole-resistant C. glabrata 3
• Remove urinary catheters if present 3

Step-Down Therapy Considerations

After initial treatment with an echinocandin and once the patient is clinically stable with negative cultures, consider step-down therapy:

• Fluconazole at higher doses (800 mg/12 mg/kg daily) only if the isolate is confirmed susceptible 1, 4
• Voriconazole (200-300 mg twice daily) for susceptible isolates 1

Special Considerations for Elderly Patients

• Echinocandins are particularly appropriate for elderly patients due to their favorable safety profile, limited adverse events, and minimal drug-drug interactions 2
• Consider potential comorbidities and drug interactions when selecting therapy 2
• Monitor renal function if using amphotericin B formulations 2
• Adjust dosing based on renal and hepatic function as needed

Monitoring During Treatment

• Monitor for treatment response through clinical assessment and follow-up cultures
• Watch for potential adverse effects:
  • Echinocandins: elevated liver enzymes and histamine-mediated reactions 1
  • Amphotericin B: nephrotoxicity and infusion-related reactions 1
• Susceptibility testing is strongly recommended for all bloodstream and clinically relevant C. glabrata isolates 1

Treatment Duration

• For most invasive infections: minimum 14 days after last positive culture and resolution of symptoms 1
• For complicated infections (endocarditis, osteomyelitis, etc.): longer durations based on infection site and clinical response

The choice of echinocandin as first-line therapy is supported by evidence showing excellent activity against C. glabrata, including fluconazole-resistant strains 5, 6, and their favorable safety profile in elderly patients 2.