What is the treatment for Candida Glabrata infection?

Treatment of Candida glabrata Infections

Echinocandins are the first-line treatment for invasive Candida glabrata infections, including candidemia and deep tissue infections, due to this species' intrinsic reduced susceptibility to azole antifungals. 1, 2

Invasive/Systemic Infections (Candidemia, Deep Tissue)

First-Line Therapy

• Initiate an echinocandin immediately for all invasive C. glabrata infections 1, 2

  • Caspofungin: 70 mg loading dose, then 50 mg daily 1
  • Micafungin: 100 mg daily 1
  • Anidulafungin: 200 mg loading dose, then 100 mg daily 1

• Continue treatment for 14 days after documented clearance of Candida from bloodstream and resolution of symptoms 1, 2

Step-Down Therapy Considerations

• Transition to fluconazole is only acceptable after initial echinocandin therapy AND documented susceptibility testing confirms fluconazole susceptibility (MIC ≤32 mcg/mL) 1, 2
• Recent evidence suggests fluconazole step-down is safe when appropriately selected, with no significant difference in 30-day clinical failure rates (9% fluconazole versus 15% echinocandin continuation) 3
• Never use fluconazole as initial monotherapy for suspected or confirmed C. glabrata 2

Alternative Therapy

• Amphotericin B deoxycholate 0.5-1.0 mg/kg daily is an alternative if echinocandins are unavailable or not tolerated 1, 2, 4
• Voriconazole 400 mg twice daily for 2 doses, then 200 mg twice daily can be used as step-down oral therapy for voriconazole-susceptible C. glabrata, but offers little advantage over fluconazole 1

Critical Management Points

• Remove all intravenous catheters and infected devices—this is strongly recommended and critical for treatment success 1, 2, 4
• Obtain antifungal susceptibility testing to guide step-down therapy decisions 1
• Patients with C. glabrata candidemia may have increased mortality, particularly in cancer patients 1

Urinary Tract Infections

Fluconazole-Susceptible C. glabrata

• Oral fluconazole 200 mg (3 mg/kg) daily for 14 days 2

Fluconazole-Resistant C. glabrata

• Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days 2, 4
• OR oral flucytosine 25 mg/kg four times daily for 7-10 days 2, 4
• Amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) may be useful, though recurrence is common 2, 4

Essential Management

• Remove indwelling bladder catheters whenever feasible—this is strongly recommended 2, 4
• Do not use lipid amphotericin B formulations for urinary tract infections 2

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 2, 4, 5
• Complete the full 14-day treatment course 2, 5

Alternative Options

• Nystatin intravaginal suppositories 100,000 units daily for 14 days 2, 4, 5
• Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream daily for 14 days 4, 5

Important Considerations

• C. glabrata vulvovaginal infections are classified as "complicated" and require different treatment approaches than C. albicans 5
• Oil-based creams and suppositories may weaken latex condoms and diaphragms 5
• Obtain vaginal cultures for confirmation, as C. glabrata doesn't form pseudohyphae or hyphae on microscopy 5
• Partner treatment is not routinely recommended 5

Oropharyngeal Candidiasis

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 2
• Voriconazole 200 mg twice daily is an alternative 2
• Intravenous echinocandin can be used for severe refractory cases 2

Respiratory Tract Colonization

Critical Pitfall to Avoid

• C. glabrata isolated from sputum represents colonization, not infection, and does NOT require antifungal treatment in the absence of invasive disease 2
• Evaluate for true invasive disease through blood cultures or tissue biopsy showing invasion before treating 2
• True Candida pneumonia is extremely rare and requires tissue diagnosis 2

Key Clinical Pitfalls

• Never assume fluconazole susceptibility in C. glabrata—this species has intrinsic reduced azole susceptibility 1, 2, 6
• C. glabrata is haploid, lacks pseudohyphae, and has facultative anaerobic growth, requiring specific diagnostic and treatment considerations 6
• Severity of illness and antifungal choice predict response, though antifungal choice does not independently influence mortality 7
• For fluconazole therapy (when susceptibility is confirmed), a dose:MIC ratio >12.5 is associated with significantly higher response rates (49% versus 20%) 7
• Patients receiving appropriate therapy have significantly lower mortality (35% versus 71% for inappropriate therapy) 8
• Approximately 12% of patients receive no antifungal therapy and contribute disproportionately to mortality 8