Treatment of Candida glabrata Surgical Site Wound Infection
An echinocandin (caspofungin, micafungin, or anidulafungin) is the preferred first-line treatment for Candida glabrata surgical site wound infections, particularly given C. glabrata's intrinsic reduced susceptibility to azoles. 1
Initial Antifungal Selection
Preferred First-Line Therapy: Echinocandins
- Caspofungin: 70 mg loading dose, then 50 mg IV daily 2, 1
- Micafungin: 100 mg IV daily 2, 1
- Anidulafungin: 200 mg loading dose, then 100 mg IV daily 2, 1
The preference for echinocandins stems from C. glabrata's intrinsic reduced azole susceptibility and superior outcomes in critically ill patients 2, 1. Echinocandins demonstrate excellent efficacy against C. glabrata with favorable safety profiles 3, 4.
Alternative Agents (Less Preferred)
- Fluconazole: 800 mg loading dose, then 400 mg daily—only if susceptibility testing confirms susceptibility AND patient is less critically ill without recent azole exposure 2, 1
- Lipid formulation amphotericin B: 3-5 mg/kg IV daily if intolerance or resistance to other agents 2, 1
- Amphotericin B deoxycholate: 0.5-1.0 mg/kg IV daily (less preferred due to toxicity) 2
Critical Management Steps
Mandatory Susceptibility Testing
- Azole susceptibility testing is mandatory for all C. glabrata isolates from surgical sites 1
- Echinocandin susceptibility testing should be considered if prior echinocandin exposure 1
Source Control
- Surgical debridement of infected tissue is strongly recommended for surgical site infections 2
- Remove or replace any indwelling devices (drains, catheters) when feasible 2, 1
- Adequate source control is essential for treatment success
Step-Down Therapy Considerations
Transition from IV echinocandin to oral azole requires documented susceptibility AND clinical stability 1:
- For fluconazole-susceptible isolates: transition to fluconazole 800 mg (12 mg/kg) daily after 5-7 days if clinically stable with negative repeat cultures 1
- For voriconazole-susceptible isolates: voriconazole 200-300 mg (3-4 mg/kg) twice daily is an option 1
- Do not transition to azole therapy without confirmed susceptibility testing 2
Treatment Duration
- Continue therapy until complete resolution of all signs and symptoms of infection 2
- Deep tissue/surgical site infections typically require longer courses than candidemia (often weeks rather than the 2-week minimum for uncomplicated candidemia) 2, 1
- Repeat cultures should be obtained to document clearance 1
Special Considerations for Fluconazole-Resistant C. glabrata
If C. glabrata is confirmed fluconazole-resistant:
- Continue echinocandin therapy as definitive treatment 2, 1
- Alternative: Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 2
- Alternative: Oral flucytosine 25 mg/kg four times daily for 7-10 days 2
Common Pitfalls to Avoid
- Do not use fluconazole empirically for C. glabrata without susceptibility data—approximately 15-20% of C. glabrata isolates demonstrate fluconazole resistance 5
- Do not rely on standard echinocandin doses in neutropenic patients—higher doses may be required for fungicidal activity 6
- Do not neglect surgical source control—antifungal therapy alone is insufficient without adequate debridement 2
- Inadequate fluconazole dosing (dose:MIC ratio ≤12.5) is associated with treatment failure when fluconazole is used 5