What is the appropriate treatment for an adult patient with suspected invasive candidiasis due to Candida albicans and Candida glabrata, both Nucleic Acid Amplification (NAA) positive and abnormal?

Treatment of Mixed Candida albicans and Candida glabrata Infection

Initiate an echinocandin immediately—specifically micafungin 100 mg IV daily, caspofungin (70 mg loading dose, then 50 mg daily), or anidulafungin (200 mg loading dose, then 100 mg daily)—as first-line therapy for this mixed infection involving C. glabrata. 1, 2, 3

Why Echinocandins Are Mandatory Here

The presence of C. glabrata fundamentally changes your treatment approach from what you might use for C. albicans alone. C. glabrata exhibits reduced susceptibility to azoles and is considered resistant to fluconazole by EUCAST guidelines 1. An echinocandin is strongly preferred for any infection involving C. glabrata 1, 2. While C. albicans typically responds well to fluconazole, the co-infection with C. glabrata mandates echinocandin therapy to ensure coverage of both species 1, 2.

For critically ill patients or those with recent azole exposure, echinocandins demonstrate superior outcomes compared to azole-based therapy 2, 3. The 2009 IDSA guidelines explicitly state that for C. glabrata infections, an echinocandin is the preferred agent, with lipid formulation amphotericin B as a less attractive alternative 1.

Essential Adjunctive Measures

• Remove all central venous catheters immediately if present—this is mandatory in non-neutropenic patients with candidemia, not optional 1, 4, 3
• Obtain daily or every-other-day blood cultures until clearance is documented 4, 2
• Perform dilated ophthalmological examination within the first week after diagnosis in non-neutropenic patients 4
• Ensure adequate source control for any intra-abdominal or deep-seated infections 1, 3

Step-Down Therapy Considerations

Do not transition to fluconazole without confirmed susceptibility testing, particularly for the C. glabrata isolate 1, 2. If the patient is clinically stable with negative follow-up cultures and susceptibility testing confirms fluconazole susceptibility for both isolates, you may consider step-down to fluconazole 400 mg (6 mg/kg) daily 1, 2. However, given C. glabrata's typical resistance patterns, continuing the echinocandin through completion of therapy is often the safer approach 1, 2.

Duration of Therapy

Continue treatment for 2 weeks after documented clearance of Candida from the bloodstream AND complete resolution of attributable symptoms 1, 4, 2, 3. This timing is critical—premature discontinuation leads to relapse 4, 2.

Critical Pitfalls to Avoid

• Never use fluconazole as initial empiric therapy when C. glabrata is suspected or confirmed—this is associated with treatment failure and increased mortality 1, 2, 5
• Do not delay antifungal initiation—delays beyond 24 hours of positive culture are associated with significantly increased mortality 2
• Do not discontinue therapy prematurely—the full 2-week post-clearance duration is necessary to prevent relapse, which occurs in approximately 36-37% of cases even with appropriate therapy 6
• Do not assume susceptibility without testing—while continuing an echinocandin is reasonable if the patient improves with negative cultures, any switch to azole therapy requires documented susceptibility 1, 2

Special Population Considerations

If the patient is neutropenic, echinocandins remain first-line, and the same duration applies (2 weeks after clearance AND resolution of neutropenia) 1, 4. For intra-abdominal candidiasis with septic shock, echinocandins are particularly critical as mortality exceeds 60% without adequate source control and appropriate antifungal therapy 1.

The combination of C. albicans and C. glabrata represents approximately 22% of intra-abdominal candidiasis cases, making this a clinically relevant scenario 1. The C. glabrata component drives your treatment decisions—treat the more resistant organism and you will adequately cover both 1, 2.