What is the recommended treatment regimen for candidemia using Anidulafungin (Ecalta)?

Anidulafungin Treatment Regimen for Candidemia

For candidemia and invasive candidiasis, administer anidulafungin with a loading dose of 200 mg intravenously on day 1, followed by 100 mg intravenously daily thereafter. 1

Dosing Regimen

• Loading dose: 200 mg IV on day 1 1
• Maintenance dose: 100 mg IV daily starting day 2 1
• Route: Intravenous administration only 1

Duration of Therapy

• Minimum duration: Continue treatment for at least 2 weeks after documented clearance of Candida from the bloodstream AND resolution of symptoms attributable to candidemia 1, 2
• Follow-up blood cultures: Obtain daily or every other day to document clearance 2, 3
• Do not discontinue prematurely: Stopping therapy before documented clearance can lead to relapse 2, 4

When Anidulafungin is Preferred

The Infectious Diseases Society of America (IDSA) 2016 guidelines provide strong recommendations for anidulafungin as initial therapy in specific clinical scenarios:

• Critically ill patients or moderately-to-severely ill patients 1
• Patients with recent azole exposure 1, 5
• Nonneutropenic ICU patients with suspected or confirmed invasive candidiasis 1
• Neutropenic patients with candidemia (strong recommendation; moderate-quality evidence) 1
• Infections with C. glabrata or C. krusei 1, 5

Step-Down Strategy

• Early switch option: After ≥5 days of IV anidulafungin, step-down to oral fluconazole (400 mg daily) or voriconazole (200 mg twice daily) is effective if the patient is clinically stable, has documented bloodstream clearance, and has a susceptible isolate 6
• Success rate: This early step-down strategy achieved 83.7% global response rate at end of treatment 6
• Criteria for step-down: Patient must be hemodynamically stable, afebrile, improving clinically, with negative follow-up blood cultures and confirmed azole-susceptible species 6

Essential Adjunctive Measures

• Central venous catheter removal: Strongly recommended as early as possible when the catheter is the presumed source 1, 2, 3
• Ophthalmologic examination: Perform dilated funduscopic examination within the first week to rule out endophthalmitis 2, 4, 3
• Imaging for persistent candidemia: Consider CT or ultrasound of genitourinary tract, liver, and spleen if blood cultures remain positive 1, 4

Special Populations and Situations

Chronic Disseminated (Hepatosplenic) Candidiasis

• Initial therapy: Anidulafungin 200 mg loading dose, then 100 mg daily for several weeks, followed by oral fluconazole 400 mg daily 1
• Duration: Continue until lesions resolve on repeat imaging, usually several months 1

Intra-abdominal Candidiasis

• Surgical intervention required: Antifungal therapy alone is insufficient; source control is mandatory 4
• Standard dosing applies: 200 mg loading dose, then 100 mg daily 4

Advantages of Anidulafungin

• No dose adjustment needed: Predictable pharmacokinetics without requirement for adjustment in hepatic or renal impairment 5, 7
• Minimal drug interactions: Can be administered with any comedication without dose modifications 5
• Well tolerated: Most common adverse events include headache, nausea, vomiting, and phlebitis/thrombophlebitis 8, 7
• Broad spectrum activity: Effective against multiple Candida species including amphotericin B- and triazole-resistant strains 8, 7

Common Pitfalls to Avoid

• Insufficient treatment duration: Failing to continue therapy for at least 2 weeks after blood culture clearance is a frequent error 2, 4
• Premature step-down: Switching to fluconazole before confirming species identification and susceptibility, especially in critically ill patients 2, 4
• Neglecting catheter removal: Not removing central venous catheters when feasible significantly impacts outcomes 2
• Skipping ophthalmologic examination: Overlooking endophthalmitis screening can miss serious complications 2
• Delayed initiation: In septic shock, mortality approaches 100% without adequate antifungal therapy within 24 hours 4

Susceptibility Testing

• Obtain for all isolates: Test azole susceptibility on all bloodstream and clinically relevant Candida isolates 1
• Echinocandin susceptibility: Consider testing in patients with prior echinocandin exposure or infections with C. glabrata or C. parapsilosis 1
• For C. auris: Test both azole and echinocandin susceptibility immediately, as 7% of isolates are echinocandin-resistant 3