From the Guidelines
Candida glabrata infections should be treated with echinocandins as first-line therapy, such as micafungin, caspofungin, or anidulafungin, due to the increasing resistance of this species to azole antifungals. The choice of echinocandin is based on factors such as the severity of illness, relevant co-morbidities, and evidence of involvement of the CNS, cardiac valves, and/or visceral organs 1. The recommended dosages for these echinocandins are: micafungin (100 mg IV daily), caspofungin (70 mg IV loading dose followed by 50 mg IV daily), or anidulafungin (200 mg IV loading dose followed by 100 mg IV daily).
Some key points to consider when treating Candida glabrata infections include:
- The risk of mortality among patients with candidemia ranges from 10% to 47%, but the actual disease-associated mortality is more likely 10%–20% 1
- Early initiation of effective antifungal therapy and source control is critical in the successful treatment of candidemia 1
- The echinocandins demonstrate significant fungicidal activity against most Candida species, and each of these agents has demonstrated success in approximately 70%–75% of patients in randomized, comparative clinical trials 1
- Fluconazole should be considered first-line therapy only in patients who are hemodynamically stable, who have had no previous exposure to azoles, and who do not belong in a group at high risk for C. glabrata infection 1
- For patients who have improved clinically following initial therapy with an echinocandin, have documented clearance of Candida from the bloodstream, and who are infected with an organism that is susceptible to fluconazole, step-down therapy to fluconazole or voriconazole may be considered 1
Treatment duration generally ranges from 14 to 21 days, depending on the severity and site of infection. Removal of infected catheters or devices is crucial for successful treatment. Patients should be monitored for treatment response with follow-up cultures and potential susceptibility testing if the infection persists despite appropriate therapy. A dilated funduscopic examination, preferably performed by an ophthalmologist, is also recommended within the first week after initiation of specific antifungal therapy to rule out ocular involvement 1.
From the FDA Drug Label
Treatment Success by Organism§ C. albicans C. glabrata C. tropicalis C. parapsilosis C. krusei C. guilliermondii C. lusitaniae 57/81 (70.4) 16/23 (69.6) 17/27 (63) 21/28 (75) 5/8 (62.5) 1/2 2/3 (66.7) 45/73 (61.6) 19/31 (61.3) 22/29 (75.9) 22/39 (56.4) 2/3 (66. 7) 0/1 2/2
The treatment success rate for C. glabrata with micafungin for injection was 69.6% (16/23) 2.
From the Research
Treatment Options for Candida Glabrata
- Echinocandins, such as micafungin, caspofungin, and anidulafungin, are commonly used to treat Candida glabrata infections 3, 4, 5
- The choice of echinocandin may depend on the specific strain of C. glabrata and its susceptibility to different echinocandins 5, 6
- Combination therapy with echinocandins and other antifungal agents, such as azoles or amphotericin B, may be effective against multidrug-resistant C. glabrata strains 7
Echinocandin Resistance
- Resistance to echinocandins is a concern, particularly among C. glabrata isolates 3, 4
- Mutations in the FKS1 and FKS2 genes are associated with echinocandin resistance 3, 4, 5
- Cross-resistance among echinocandins has been observed, with some isolates resistant to multiple echinocandins 7
Clinical Considerations
- The choice of antifungal therapy should be guided by susceptibility testing and clinical experience 3, 4, 5
- Combination therapy may be considered for patients with multidrug-resistant C. glabrata infections 7
- Switching from one echinocandin to another may be an option if the initial therapy is not effective 6