Fluconazole step-down therapy versus echinocandins for the treatment of Candida glabrata invasive candidiasis with candidaemia.

objectivesCandida glabrata is the second most common species responsible for invasive candidiasis, including candidaemia. Echinocandins are typically the first-line therapy for C. glabrata candidaemia, with the option to transition to oral fluconazole. Studies are needed to evaluate clinical outcomes in patients initially treated with echinocandins then transitioned to fluconazole.

methodsThis was a retrospective, single-centre cohort study of patients with C. glabrata candidaemia from November 2011 to August 2023. Inpatients aged 18-89 years who received an echinocandin within 24 h of the initial positive blood culture were included. Patients were excluded if they received antifungal treatment less than 48 h, combination therapy, or fluconazole as initial therapy. The primary composite outcome was 30-day clinical failure.

resultsA total of 186 patients were included (n = 153 echinocandin only; n = 33 fluconazole step-down). The most common source of candidaemia was line-associated in both groups with the majority having source control (43% echinocandin versus 58% fluconazole; P = 0.32). Compared to fluconazole, patients in the echinocandin group had a higher rate of concomitant bacteraemia (45% versus 24%; P = 0.03) and endovascular complications (11% versus 0%; P = 0.05). There was no significant difference in treatment duration between echinocandin and fluconazole (16 versus 19 days; P = 0.46), incidence of persistent candidaemia (22% versus 24%; P = 0.7), or 30-day clinical failure (15% versus 9%; P = 0.58).

conclusionsFluconazole appears to be a safe and reasonable step-down therapy in the management of C. glabrata candidaemia.