Treatment of Candida glabrata Bacteremia from Urinary Source
For C. glabrata candidemia originating from a urinary source, treat as candidemia (not as isolated UTI) with an echinocandin as first-line therapy, followed by fluconazole step-down if the isolate is susceptible, while simultaneously addressing urinary tract source control. 1
Critical Distinction: Candidemia vs. Candiduria
The key clinical principle is recognizing that C. glabrata in blood cultures represents candidemia requiring systemic treatment, regardless of urinary origin. 1 This differs fundamentally from isolated candiduria, where treatment is often unnecessary. When candidemia develops from a urinary source, you are treating bloodstream infection with kidney involvement, not simple UTI. 1
Initial Antifungal Therapy
First-Line Treatment
- Initiate an echinocandin (caspofungin, micafungin, or anidulafungin) immediately as first-line therapy for C. glabrata candidemia 1
- Echinocandins achieve adequate tissue concentrations in kidneys despite poor urinary excretion, making them effective for hematogenous renal involvement 1
- Recent evidence shows echinocandins are not inferior to fluconazole for C. glabrata candidemia outcomes 2, 3
Step-Down Therapy
- Transition to oral fluconazole 400-800 mg (6-12 mg/kg) daily if susceptibility testing confirms fluconazole susceptibility 1, 2
- Step-down typically occurs after clinical improvement and negative repeat blood cultures 2
- A 2025 study demonstrated fluconazole step-down after initial echinocandin therapy resulted in similar 30-day clinical failure rates (9% vs 15%) compared to continued echinocandin therapy 2
Alternative for Fluconazole-Resistant C. glabrata
- If fluconazole-resistant, use amphotericin B deoxycholate 0.3-0.6 mg/kg daily with or without flucytosine 25 mg/kg four times daily 1
- Lipid formulations of amphotericin B should NOT be used for urinary tract involvement as they do not achieve adequate urine concentrations 1
Essential Source Control Measures
Urinary Tract Interventions
- Remove indwelling bladder catheters immediately if present 1
- Eliminate any urinary tract obstruction (this is critical and strongly recommended) 1
- Remove or replace nephrostomy tubes or ureteral stents if feasible 1
- Failure to address obstruction precludes successful antifungal treatment alone, as fungus balls cannot be cleared pharmacologically 1
Surgical Considerations
- Surgical intervention is strongly recommended for complicated cases (abscesses, fungus balls, emphysematous pyelonephritis) 1
- Percutaneous drainage may be necessary for obstructive pyonephrosis 4
Treatment Duration
- Continue therapy for at least 2 weeks after documented clearance of candidemia and resolution of symptoms 1
- Obtain repeat blood cultures to document clearance 5
- Duration may extend to 4-6 weeks depending on complications and source control 1
Important Caveats and Pitfalls
Echinocandin Limitations
- Echinocandins do NOT achieve adequate urine concentrations and should not be used as monotherapy for isolated cystitis or pyelonephritis without candidemia 1
- However, for candidemia with renal involvement (hematogenous spread), echinocandins work because tissue concentrations are adequate 1
- A 2006 case report demonstrated caspofungin failure in obstructive pyonephrosis, requiring local amphotericin B instillation 4
Fluconazole Considerations
- C. glabrata has inherently reduced susceptibility to fluconazole, making susceptibility testing mandatory before step-down 1, 3
- Despite concerns, a 2016 propensity-matched analysis found fluconazole was not associated with worse outcomes when used appropriately for susceptible C. glabrata candidemia 3