What is the recommended treatment and dosage for candidiasis using Anidulafungin (Ecalta)?

Anidulafungin Treatment for Candidiasis

For the treatment of invasive candidiasis, anidulafungin should be administered at a loading dose of 200 mg on day 1, followed by 100 mg daily, with treatment continuing for at least 2 weeks after documented clearance of Candida from the bloodstream and resolution of symptoms. 1

Dosage Recommendations by Type of Infection

Invasive Candidiasis/Candidemia

• Loading dose: 200 mg intravenously on day 1
• Maintenance dose: 100 mg intravenously daily thereafter 1
• Duration: Continue for at least 2 weeks after documented clearance of Candida from the bloodstream and resolution of symptoms 2

Esophageal Candidiasis

• Loading dose: 100 mg intravenously on day 1
• Maintenance dose: 50 mg intravenously daily thereafter 3
• Duration: 14-21 days 2

Clinical Efficacy

Anidulafungin demonstrates excellent efficacy against Candida infections. In a pivotal clinical trial, anidulafungin showed superior global response rates compared to fluconazole (70.8% vs. 54.1%) in critically ill patients with candidemia 4. This supports the Infectious Diseases Society of America (IDSA) recommendation of echinocandins as first-line therapy for invasive candidiasis, particularly in moderately to severely ill patients 1.

Patient Selection and Considerations

Anidulafungin is particularly appropriate for:

1. Critically ill patients with invasive candidiasis or candidemia 1, 4
2. Patients with recent azole exposure 1
3. Infections with potentially azole-resistant Candida species (e.g., C. glabrata, C. krusei) 1
4. Patients with hepatic or renal impairment (no dose adjustment required) 3

Special Populations

Pediatric Patients (2 to <18 years)

• Safety and efficacy established for invasive candidiasis 5
• Dosage: 3 mg/kg loading dose on day 1, followed by 1.5 mg/kg daily 5

Hepatic Impairment

• No dosage adjustments required for any degree of hepatic insufficiency 3
• Anidulafungin is not hepatically metabolized 3

Renal Impairment

• No dosage adjustments required for any degree of renal insufficiency, including patients on hemodialysis 3
• Anidulafungin has negligible (<1%) renal clearance 3

Monitoring and Management

• Follow-up blood cultures should be performed daily or every other day to establish clearance of candidemia 2
• A dilated ophthalmological examination is recommended within the first week after diagnosis for all non-neutropenic patients with candidemia 2
• Central venous catheters should be removed as early as possible when the source is presumed to be the catheter 2
• For persistent candidemia, imaging of the genitourinary tract, liver, and spleen should be performed to rule out deep-seated infection 2

Chronic Disseminated (Hepatosplenic) Candidiasis

For chronic disseminated candidiasis, anidulafungin (200 mg loading dose, then 100 mg daily) is recommended as initial therapy for several weeks, followed by oral fluconazole 400 mg daily for patients unlikely to have fluconazole-resistant isolates 1. Therapy should continue until lesions resolve on repeat imaging, which usually takes several months 1.

Adverse Effects

Anidulafungin is generally well tolerated. Common adverse effects include:

• Phlebitis/thrombophlebitis
• Headache
• Gastrointestinal symptoms (diarrhea, nausea, vomiting)
• Pyrexia
• Abnormal liver function tests 6, 7

Advantages Over Other Antifungals

• No dose adjustments required for hepatic or renal impairment 3
• Minimal drug-drug interactions due to lack of interference with cytochrome P450 pathway 8
• Effective against fluconazole-resistant Candida strains 8, 7
• Superior efficacy compared to fluconazole in critically ill patients 4

Clinical Pitfalls to Avoid

1. Inadequate treatment duration: Ensure therapy continues for at least 2 weeks after documented clearance of candidemia
2. Failure to remove central venous catheters: When possible, remove catheters in patients with candidemia
3. Overlooking ophthalmologic examination: Essential to rule out endophthalmitis
4. Premature discontinuation of therapy: Can lead to relapse, particularly in chronic disseminated candidiasis
5. Failure to transition therapy: For stable patients with susceptible isolates, consider step-down to oral fluconazole after clinical improvement

By following these evidence-based recommendations, clinicians can optimize outcomes for patients with candidiasis requiring treatment with anidulafungin.