Acquired multidrug-resistant Candida glabrata in Australia: a case report

Background: Candida glabrata is the second most common cause of candidaemia in Australia, and echinocandins remain the first-line choice for empirical treatment. There have been increasing reports of multidrug-resistant (MDR) C. glabrata worldwide. To date, there have been no documented cases of MDR C. glabrata in Australia. This paper describes a case of C. glabrata resistant to azole antifungals and echinocandins in Australia. Clinical details: A 47-year-old male was admitted for management of acute graft-versus-host disease (GVHD) of the gastrointestinal tract on Day 129 after allogeneic haematopoietic stem cell transplant for chronic lymphocytic leukaemia. On Day 38 of admission, the patient developed C. glabrata candidaemia that was susceptible to echinocandins but resistant to azole antifungals. The patient received a 17-day course of intravenous (IV) caspofungin with subsequent negative blood cultures. However, on Day 67, the patient again developed C. glabrata candidaemia that now exhibited resistance to echinocandins and azole antifungals. Outcomes: The patient was commenced on liposomal amphotericin B (3 mg/kg, IV, daily) by the infectious diseases unit. A literature search by the pharmacist prompted a recommendation of a dose increase to 5 mg/kg, IV, daily given this isolate had a high minimum inhibitory concentration of 1 microgram/mL. Liposomal amphotericin B continued for 14 days with no further positive blood cultures. Unfortunately the patient died on Day 92 of admission secondary to severe treatment-refractory GVHD. Conclusion: This case highlights a case of MDR C. glabrata in Australia, which is of concern given the recommended empirical use of echinocandins for candidaemia.