What is the recommended treatment for Candida glabrata in urine?

Treatment of Candida glabrata in Urine

For symptomatic Candida glabrata urinary tract infections, amphotericin B deoxycholate 0.3-0.6 mg/kg IV daily for 1-7 days (for cystitis) or 0.5-0.7 mg/kg daily for 2 weeks (for pyelonephritis) is the recommended treatment, as C. glabrata is frequently fluconazole-resistant. 1, 2

Initial Assessment: Determine if Treatment is Needed

Most patients with C. glabrata candiduria do not require antifungal therapy. 1, 2

High-Risk Groups Requiring Treatment:

• Neutropenic patients (treat as candidemia) 1, 2
• Low birth weight neonates (<1500g) 1, 2
• Patients undergoing urologic procedures 1, 2
• Severely immunocompromised patients with fever and candiduria 1

First-Line Intervention Before Antifungals:

• Remove urinary catheters immediately if feasible—this resolves candiduria in approximately 50% of cases without antifungal therapy 1, 2, 3
• Eliminate other predisposing factors (antibiotics, obstruction) 1, 2

Treatment Algorithm for Symptomatic Infection

For Cystitis (Lower UTI):

• Amphotericin B deoxycholate 0.3-0.6 mg/kg IV daily for 1-7 days 1, 2
• Alternative: Flucytosine 25 mg/kg orally 4 times daily for 7-10 days 1, 2
• Bladder irrigation with amphotericin B (50 mg/L sterile water) may be considered as adjunctive therapy for refractory cases, though relapse rates are high 1

For Pyelonephritis (Upper UTI):

• Amphotericin B deoxycholate 0.5-0.7 mg/kg IV daily for 2 weeks 1, 2
• Alternative: Flucytosine 25 mg/kg orally 4 times daily for 2 weeks 1
• Combination therapy: Amphotericin B 0.5-0.7 mg/kg daily PLUS flucytosine 25 mg/kg 4 times daily 1

For Fungus Balls:

• Surgical debridement is strongly recommended 1
• Systemic amphotericin B 0.5-0.7 mg/kg daily with or without flucytosine 1
• If nephrostomy access available: irrigation with amphotericin B 50 mg/L as adjunct 1

Why C. glabrata Requires Different Treatment

C. glabrata accounts for approximately 20% of adult urinary Candida isolates and exhibits intrinsic or acquired fluconazole resistance in most cases. 1, 2 This makes fluconazole—the standard first-line agent for other Candida species—ineffective for C. glabrata infections. 1, 2

Critical Pitfalls to Avoid

Do NOT Use These Agents:

• Echinocandins (caspofungin, micafungin, anidulafungin): Achieve minimal urinary concentrations and have documented treatment failures despite in vitro activity 1, 4, 3, 5
• Lipid formulations of amphotericin B: Do not achieve adequate renal tissue or urine concentrations 1
• Voriconazole and other azoles (except fluconazole): Minimal urinary excretion makes them ineffective for UTI 1, 3
• Fluconazole: Ineffective due to resistance patterns in C. glabrata 1, 2

Important Caveat on Echinocandins:

While some case reports describe successful treatment with echinocandins 6, 7, the IDSA guidelines explicitly do not recommend them due to poor urinary concentrations and documented failures, particularly in obstructive infections 1, 4. One case report documented complete failure of caspofungin for C. glabrata pyonephrosis despite in vitro susceptibility, requiring drainage and local amphotericin B instillation for cure. 4

Treatment Duration and Monitoring

• Continue treatment until symptoms resolve AND urine cultures are negative for Candida 1
• Standard duration: 2 weeks for uncomplicated infections 1
• Obtain follow-up urine cultures to document clearance 1
• If fever persists despite appropriate therapy, obtain imaging to rule out obstruction, fungus balls, or abscesses 1

Special Considerations for Urologic Procedures

For patients undergoing urologic manipulation with C. glabrata candiduria, prophylactic amphotericin B 0.3-0.6 mg/kg daily for several days before and after the procedure is recommended. 1 Fluconazole should not be used for C. glabrata prophylaxis due to resistance. 2