What is the recommended treatment for a 78-year-old woman with a Candida glabrata Urinary Tract Infection (UTI)?

Treatment of Candida glabrata UTI in a 78-year-old Woman

For a 78-year-old woman with Candida glabrata urinary tract infection, oral fluconazole is not recommended as first-line therapy due to frequent resistance; instead, treatment should begin with removal of any urinary catheter if present, followed by an echinocandin such as caspofungin 70mg loading dose then 50mg daily for 14 days. 1, 2

Initial Management Steps

1. Remove predisposing factors:

   • Remove indwelling bladder catheter if present (resolves candiduria in ~50% of cases)
   • Correct any urinary tract obstruction
   • Replace or remove nephrostomy tubes/stents if present
   • Ensure adequate hydration 2

2. Diagnostic confirmation:

   • Obtain urine culture to confirm C. glabrata and determine susceptibility
   • Order blood cultures to rule out candidemia, especially if fever is present
   • Complete metabolic panel to assess renal function 2

Antifungal Therapy Options

First-line Treatment

For C. glabrata UTI (which is often fluconazole-resistant):

• Echinocandin therapy (despite limited urinary concentrations, effective for tissue invasion):
  • Caspofungin: 70mg IV loading dose, then 50mg IV daily for 14 days 1, 3
  • Micafungin: 150mg IV daily for 14 days 2, 4
  • Anidulafungin: 200mg IV loading dose, then 100mg IV daily for 14 days 1

Alternative Options

If echinocandins cannot be used or for less severe infections:

• Amphotericin B deoxycholate: 0.3-0.6 mg/kg IV daily for 1-7 days 2
• Flucytosine: 25 mg/kg orally 4 times daily for 7-10 days 2
• Intravaginal boric acid: 600mg daily for 14 days (if vulvovaginal involvement) 1

Special Considerations for C. glabrata

1. Resistance patterns:

   • C. glabrata frequently shows reduced susceptibility to fluconazole
   • Echinocandins are preferred despite suboptimal urinary concentrations due to tissue penetration 4

2. Treatment duration:

   • Minimum 14 days of therapy
   • Continue until symptoms resolve and urine cultures become negative 2

3. Monitoring:

   • Follow-up urine cultures to confirm eradication
   • Monitor renal function, especially in elderly patients
   • Assess for clinical improvement of symptoms 2

Management of Complications

1. Fungus ball formation:

   • Surgical or endoscopic removal is central to successful treatment
   • Consider irrigation through nephrostomy tubes with amphotericin B if present 1, 2

2. Persistent infection:

   • Consider imaging to rule out anatomical abnormalities
   • Evaluate for underlying immunosuppression
   • Consider combination therapy in refractory cases 2

Pitfalls and Caveats

• Do not use fluconazole as first-line therapy for C. glabrata UTI due to frequent resistance
• Do not leave urinary catheters in place during treatment as they serve as a nidus for infection
• Do not assume treatment failure too early - clinical response may take several days
• Avoid unnecessary treatment of asymptomatic candiduria in non-high-risk patients
• Remember that echinocandins achieve poor urinary concentrations but are still effective for tissue invasion in C. glabrata infections 2, 5, 4