Treatment of Candida glabrata in Urine
For symptomatic C. glabrata cystitis, use 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, as C. glabrata is frequently fluconazole-resistant. 1
Initial Assessment: Determine if Treatment is Needed
Most patients with C. glabrata in urine do not require antifungal therapy. The critical first step is determining whether the patient falls into a high-risk category requiring treatment 2:
Asymptomatic patients who DO require treatment:
- Neutropenic patients (treat as candidemia) 1, 2
- Very low-birth-weight infants (<1500g) 1, 2
- Patients undergoing urologic procedures within several days 1, 2
Asymptomatic patients who do NOT require treatment:
- Otherwise healthy individuals with candiduria should only be observed 1, 3
- Removing the urinary catheter alone clears candiduria in approximately 50% of asymptomatic patients 4
Treatment Algorithm for Symptomatic Infections
For Cystitis (Lower Urinary Tract)
First-line therapy for fluconazole-resistant C. glabrata:
- Amphotericin B deoxycholate 0.3–0.6 mg/kg IV daily for 1–7 days 1, 2
- OR oral flucytosine 25 mg/kg four times daily for 7–10 days 1, 2
Critical adjunctive measure:
- Remove indwelling urinary catheter if present (this is a strong recommendation and essential for treatment success) 1, 2
Alternative consideration:
- Amphotericin B deoxycholate bladder irrigation (50 mg/L sterile water daily for 5 days) may be useful for fluconazole-resistant C. glabrata cystitis, though this is a weak recommendation 1
For Pyelonephritis (Upper Urinary Tract)
For fluconazole-resistant C. glabrata pyelonephritis:
- Amphotericin B deoxycholate 0.5–0.7 mg/kg IV daily for 2 weeks 1
- May add flucytosine 25 mg/kg four times daily (combination therapy) 1
- OR flucytosine monotherapy 25 mg/kg four times daily for 2 weeks (weak recommendation, consider only when amphotericin cannot be used) 1
Essential interventions:
- Eliminate urinary tract obstruction if present 1
- Consider removal or replacement of nephrostomy tubes or stents if feasible 1
Why C. glabrata Requires Different Treatment
C. glabrata represents approximately 20% of urinary Candida isolates in adults and has intrinsic or acquired fluconazole resistance in many cases 2, 3. This makes fluconazole—the standard first-line agent for most Candida urinary infections—inappropriate for C. glabrata 2.
Critical Pitfalls to Avoid
Do NOT use echinocandins for C. glabrata urinary tract infections:
- Echinocandins (caspofungin, micafungin, anidulafungin) achieve minimal urinary concentrations and have documented therapeutic failures 2
- Despite one case report of successful micafungin use 5, current guidelines do not support this approach due to inadequate urinary drug levels 2
- The combination of caspofungin plus flucytosine should be avoided due to rapid development of flucytosine resistance 6
Do NOT use other azoles:
- Voriconazole, posaconazole, and itraconazole achieve minimal urinary concentrations and are ineffective for lower urinary tract infections 3, 4
Flucytosine monotherapy limitations:
- While flucytosine has good activity against C. glabrata, monotherapy is limited by toxicity and rapid resistance development 1, 2
- Use with caution and monitor for adverse effects 1
Pre-Procedure Prophylaxis
For patients with C. glabrata candiduria undergoing urologic procedures:
- Fluconazole 400 mg (6 mg/kg) daily OR amphotericin B deoxycholate 0.3–0.6 mg/kg daily for several days before and after the procedure 1
Treatment Duration
Continue therapy until symptoms resolve and urine cultures are negative for Candida species 1:
Special Considerations
For suspected disseminated candidiasis with candiduria:
- Treat as candidemia with systemic echinocandin therapy, not as isolated urinary infection 1
For fungus balls: