What is the treatment for Candida glabrata infection?

Treatment of Candida glabrata and Candida krusei Infections

For invasive Candida glabrata infections, echinocandins (caspofungin, micafungin, or anidulafungin) are the first-line therapy due to this species' intrinsic reduced susceptibility to azoles. 1, 2

Systemic/Invasive Infections (Candidemia, Deep Tissue)

First-Line Treatment

• Echinocandins are strongly preferred for all invasive C. glabrata infections, including candidemia and deep tissue infections 1, 3, 2
• Standard echinocandin dosing applies (e.g., caspofungin 70 mg loading dose, then 50 mg daily; micafungin 100 mg daily; anidulafungin 200 mg loading dose, then 100 mg daily) 4
• Treatment duration typically 14 days after documented clearance and resolution of symptoms 1

Step-Down Therapy

• Fluconazole step-down (200-400 mg daily) can be considered only after initial echinocandin therapy AND documented susceptibility testing confirms fluconazole susceptibility (MIC ≤32 mcg/mL) 1, 5
• Recent evidence supports fluconazole step-down as safe and reasonable after initial echinocandin treatment in appropriate patients 5
• Never use fluconazole as initial monotherapy for suspected or confirmed C. glabrata due to high resistance rates 3, 2

Alternative Therapy for Fluconazole-Resistant Strains

• Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days with or without oral flucytosine 25 mg/kg four times daily 1, 2
• Note: Lipid formulations of amphotericin B should NOT be used for urinary tract infections due to inadequate urinary excretion 1

C. krusei Treatment

• C. krusei is intrinsically resistant to fluconazole 1
• Echinocandins remain first-line for invasive C. krusei infections 1
• Amphotericin B deoxycholate 0.3-0.6 mg/kg daily is an alternative 1

Urinary Tract Infections

Cystitis (Lower UTI)

• For fluconazole-susceptible C. glabrata: Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks 1
• For fluconazole-resistant C. glabrata: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days OR oral flucytosine 25 mg/kg four times daily for 7-10 days 1, 2
• For C. krusei: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1, 2
• Amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) may be useful for fluconazole-resistant species, though recurrence is common 1, 2
• Removal of indwelling bladder catheter is strongly recommended whenever feasible 1, 2

Pyelonephritis (Upper UTI)

• For fluconazole-susceptible organisms: Oral fluconazole 200-400 mg (3-6 mg/kg) daily for 2 weeks 1
• For fluconazole-resistant C. glabrata: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days with or without oral flucytosine 25 mg/kg four times daily 1
• Monotherapy with oral flucytosine 25 mg/kg four times daily for 2 weeks could be considered (weaker recommendation) 1
• For C. krusei: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 1
• Elimination of urinary tract obstruction is strongly recommended 1

Critical Caveat for UTI Treatment

• Echinocandins have minimal urinary excretion and are generally ineffective for urinary candidiasis, though they may work for kidney parenchymal infection from hematogenous spread 1
• Voriconazole does not accumulate in active form in urine and should not be used for urinary candidiasis 1

Vulvovaginal Candidiasis

First-Line Treatment

• Topical intravaginal boric acid in gelatin capsule, 600 mg daily for 14 days is the preferred treatment for C. glabrata vulvovaginitis, especially when oral azoles are ineffective 6, 2

Alternative Options

• Nystatin intravaginal suppositories 100,000 units daily for 14 days 6, 2
• Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream daily for 14 days (weaker recommendation) 6, 2
• Non-fluconazole azole drugs for 7-14 days can be considered 6

Important Considerations

• C. glabrata vulvovaginitis is classified as "complicated" and requires different treatment than C. albicans 6
• Avoid fluconazole monotherapy for confirmed C. glabrata vaginal infections 6
• Complete the full 14-day treatment course 6, 2
• Oil-based preparations may weaken latex condoms and diaphragms 6

Oropharyngeal Candidiasis

For Fluconazole-Refractory Disease

• Itraconazole solution 200 mg once daily OR posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 1
• Voriconazole 200 mg twice daily is an alternative 1
• Intravenous echinocandin can be used for severe refractory cases 1

Respiratory Tract Colonization

Critical Point: C. glabrata isolated from sputum represents colonization, not infection, and does NOT require antifungal treatment in the absence of invasive disease 3

• Evaluate for true invasive disease through blood cultures or tissue biopsy showing invasion before treating 3
• True Candida pneumonia is extremely rare and requires tissue diagnosis 3
• Treating sputum colonization leads to unnecessary antifungal exposure, drug resistance, and adverse effects 3

Key Clinical Pitfalls

1. Never assume fluconazole susceptibility in C. glabrata—this species has intrinsic reduced azole susceptibility 1, 3
2. Always remove infected devices (catheters, lines, stents) when feasible—this is critical for treatment success 1, 2
3. Obtain susceptibility testing to guide step-down therapy decisions 1, 5
4. Do not use lipid amphotericin B formulations for urinary tract infections 1
5. Do not treat respiratory colonization—document invasive disease first 3