Treatment of Candida glabrata Infections
For C. glabrata infections, treatment should be tailored to the site of infection, with echinocandins as first-line therapy for systemic infections and topical agents for localized infections due to intrinsic azole resistance in this species. 1
Systemic C. glabrata Infections
Candidemia/Invasive Candidiasis
- For fluconazole-resistant C. glabrata (which is common), amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days with or without oral flucytosine (25 mg/kg 4 times daily) is recommended 1
- Echinocandins (e.g., caspofungin) are preferred for C. glabrata infections as they demonstrate good activity against this species 1
- Prior fluconazole exposure is a significant risk factor for developing fluconazole-resistant C. glabrata infections (OR 12.24) 2
Urinary Tract Infections
- For C. glabrata cystitis, 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 recommended 1
- Amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) may be useful for treating cystitis due to fluconazole-resistant C. glabrata 1
- Removal of indwelling bladder catheters is strongly recommended whenever feasible 1
Pyelonephritis
- For C. glabrata pyelonephritis, amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days with or without oral flucytosine is recommended 1
- For patients with nephrostomy tubes, consider removal or replacement if feasible 1
- Elimination of urinary tract obstruction is strongly recommended 1
Vulvovaginal C. glabrata Infections
First-line Treatment
- For C. glabrata vulvovaginitis unresponsive to oral azoles, topical intravaginal boric acid administered in a gelatin capsule, 600 mg daily for 14 days is recommended 1
Alternative Treatments
- Nystatin intravaginal suppositories, 100,000 units daily for 14 days 1
- Topical 17% flucytosine cream alone or in combination with 3% amphotericin B cream administered daily for 14 days 1
Special Considerations
Antifungal Susceptibility
- C. glabrata often has reduced susceptibility to azoles, particularly fluconazole 1, 2
- Fluconazole resistance was found in 11% of C. glabrata isolates in ICU settings 3
- Expression of drug efflux pump-encoding genes (CgCDR1 and CgCDR2) is up-regulated in fluconazole-resistant and susceptible-dose-dependent isolates 2
Risk Factors for Resistant Infections
- Prior fluconazole use (OR 12.24), diabetes (OR 10.47), and central venous catheters (OR 8.48) are independent risk factors for fungemia due to less-susceptible C. glabrata isolates 2
- When candidemia is suspected in patients with prior azole exposure, broader-spectrum antifungals (echinocandins or amphotericin B) should be considered as initial treatment 2
Treatment Outcomes
- Despite higher fluconazole resistance, C. glabrata candidemia was not associated with greater mortality than non-glabrata candidemia in ICU settings 3
- Therapeutic regimens containing amphotericin B were associated with better outcomes in C. glabrata fungemia 3
- Inadequate antifungal treatment (e.g., empiric fluconazole for resistant isolates) is associated with high mortality 2
Common Pitfalls and Caveats
- Empiric fluconazole should be avoided for suspected C. glabrata infections due to intrinsic reduced susceptibility 2
- Removal of infected devices (catheters, shunts, etc.) is crucial for successful treatment 1
- C. glabrata is often considered a species of low virulence but can be associated with higher mortality rates than C. albicans 4
- Environmental contamination by C. glabrata through healthcare workers' hands may facilitate infections in immunocompromised patients 4