What is the recommended treatment for a patient with a surgical site wound infected with Candida glabrata that is resistant to fluconazole (an antifungal medication)?

Treatment of Fluconazole-Resistant Candida glabrata Surgical Site Wound Infection

An echinocandin (caspofungin, micafungin, or anidulafungin) is the recommended first-line treatment for fluconazole-resistant Candida glabrata surgical site wound infections. 1

Primary Treatment Recommendation

Initiate an echinocandin immediately for this fluconazole-resistant C. glabrata infection, as guidelines explicitly state to favor echinocandins for patients at high risk of infection due to fluconazole-resistant Candida species such as C. glabrata. 1

Echinocandin Options:

• Caspofungin: Loading dose 70 mg IV on day 1, then 50 mg IV daily 1
• Micafungin: 100 mg IV daily 1
• Anidulafungin: Loading dose 200 mg IV on day 1, then 100 mg IV daily 1

Alternative Treatment Options (If Echinocandins Unavailable or Not Tolerated)

Second-Line: Lipid Formulation Amphotericin B

• Liposomal amphotericin B 3-5 mg/kg daily is a reasonable alternative if there is intolerance, limited availability, or resistance to echinocandins. 1
• This option is particularly appropriate for deep tissue Candida infections including surgical site wounds. 2

Third-Line: Voriconazole (Only If Susceptibility Confirmed)

• Voriconazole 400 mg (6 mg/kg) IV twice daily for 2 doses, then 200 mg (3 mg/kg) twice daily can be considered ONLY if susceptibility testing confirms the isolate is voriconazole-susceptible. 1, 2
• Voriconazole is more potent in vitro against C. glabrata than fluconazole and may be reasonable for these infections. 1
• Therapeutic drug monitoring should be performed when using voriconazole. 1
• Clinical data shows voriconazole achieved success in 3 of 3 patients with deep tissue abscess or wound infections. 2

Fourth-Line: High-Dose Fluconazole (Only If Susceptibility Confirmed)

• Fluconazole 800 mg (12 mg/kg) daily should ONLY be considered if susceptibility testing confirms fluconazole-susceptible isolate (which contradicts your stated resistance). 1
• Since your isolate is fluconazole-resistant, this option is NOT appropriate. 1

Critical Adjunctive Measures

Surgical debridement and source control are essential for surgical site wound infections:

• Remove any foreign material, necrotic tissue, or infected devices if present. 1
• Adequate drainage and wound care are mandatory for successful treatment. 1

Antifungal Susceptibility Testing

Obtain antifungal susceptibility testing immediately to guide definitive therapy, as testing is recommended for treatment failure or prior azole exposure. 1

• This will confirm resistance patterns and guide potential step-down therapy. 1
• Testing should include susceptibility to echinocandins, amphotericin B, and voriconazole. 1

Duration of Therapy

Continue treatment for at least 14 days after documented clearance of infection and resolution of signs and symptoms. 1

• For deep tissue infections like surgical site wounds, longer duration may be necessary depending on clinical response. 1
• Repeat cultures from the wound site should be performed to document clearance. 1

Important Clinical Caveats

Do NOT use flucytosine monotherapy, as resistance develops rapidly; however, combination therapy with amphotericin B plus flucytosine may be considered for severe or refractory cases. 1, 3

Avoid fluconazole entirely given documented resistance—even high-dose fluconazole is inappropriate when resistance is confirmed. 1

Monitor for treatment response within 48-72 hours and modify therapy if clinical improvement is not observed. 1