What is the recommended treatment for a blood culture positive for Candida glabrata?

Treatment of Blood Culture Positive for Candida glabrata

An echinocandin (caspofungin: loading dose 70 mg, then 50 mg daily; micafungin: 100 mg daily; or anidulafungin: loading dose 200 mg, then 100 mg daily) is the recommended first-line therapy for bloodstream infections caused by Candida glabrata. 1

Initial Management

• Initiate an echinocandin as first-line therapy due to C. glabrata's frequent reduced susceptibility to fluconazole 1
• Remove central venous catheters if present, as this is a critical intervention for candidemia management 2
• Obtain follow-up blood cultures every day or every other day to document clearance of the organism 1
• Perform susceptibility testing on all C. glabrata isolates to guide therapy 1
• Conduct a dilated ophthalmological examination within the first week after diagnosis to rule out endophthalmitis 1
• Consider imaging of the genitourinary tract, liver, and spleen if blood cultures remain persistently positive 2

Treatment Options

First-line therapy:

• Echinocandin (strong recommendation; high-quality evidence) 1:
  • Caspofungin: 70 mg loading dose, then 50 mg daily
  • Micafungin: 100 mg daily
  • Anidulafungin: 200 mg loading dose, then 100 mg daily

Alternative options (if echinocandins cannot be used):

• Lipid formulation amphotericin B (3-5 mg/kg daily) (strong recommendation; high-quality evidence) 1
• High-dose fluconazole (800 mg [12 mg/kg] daily) may be considered only for isolates proven susceptible to fluconazole (strong recommendation; low-quality evidence) 1
• Voriconazole (200-300 mg [3-4 mg/kg] twice daily) may be considered only for fluconazole-susceptible or voriconazole-susceptible isolates (strong recommendation; low-quality evidence) 1

Step-down Therapy Considerations

• Transition from an echinocandin to fluconazole should only be considered for patients with C. glabrata if 1:
  • The isolate is proven susceptible to fluconazole
  • The patient is clinically stable
  • Repeat blood cultures are negative
• For C. glabrata, higher-dose fluconazole (800 mg [12 mg/kg] daily) should be used if step-down therapy is considered 1
• Recent evidence suggests fluconazole step-down therapy may be reasonable in selected patients with C. glabrata candidemia who have responded to initial echinocandin therapy 3

Duration of Therapy

• Continue antifungal therapy for at least 2 weeks after documented clearance of Candida from the bloodstream and resolution of symptoms attributable to candidemia 1
• Longer therapy may be required if there are metastatic complications 2

Special Considerations

• C. glabrata has shown higher mortality rates when treated with azole monotherapy compared to echinocandins or polyenes in cancer patients 4
• Higher doses of echinocandins may be required to achieve fungicidal effects in neutropenic hosts with C. glabrata infections 5
• For persistent candidemia despite appropriate therapy, consider:
  • Inadequate source control 2
  • Development of resistance 1
  • Presence of metastatic foci of infection 2

Common Pitfalls to Avoid

• Failing to remove central venous catheters, which is a common reason for persistent candidemia 2
• Using fluconazole as initial therapy without confirmed susceptibility testing 1
• Premature discontinuation of therapy before documented clearance, which can lead to relapse 2
• Failure to identify and address metastatic foci of infection (endocarditis, osteomyelitis, endophthalmitis) 2

By following these evidence-based recommendations, clinicians can optimize outcomes for patients with C. glabrata bloodstream infections, reducing morbidity and mortality associated with this serious infection.