What is the recommended administration protocol for micafungin (Intravenous Antifungal Agent) for the treatment of invasive candidiasis?

Micafungin Administration Protocol

Route and Infusion Parameters

Micafungin must be administered by intravenous infusion only, infused over one hour; more rapid infusions may result in histamine-mediated reactions. 1

• Administer as a slow IV infusion over 1 hour to minimize infusion-related reactions 1
• Flush existing IV lines with 0.9% Sodium Chloride Injection prior to micafungin infusion 1
• Concentrations above 1.5 mg/mL should be administered via central catheter to decrease risk of infusion reactions 1

Reconstitution and Preparation

Strict aseptic technique must be observed during all handling, as micafungin contains no preservatives or bacteriostatic agents. 1

Reconstitution Steps:

• Reconstitute 50 mg vial with 5 mL of diluent (final concentration 10 mg/mL) or 100 mg vial with 5 mL of diluent (final concentration 20 mg/mL) 1
• Use either 0.9% Sodium Chloride Injection or 5% Dextrose Injection as diluent 1
• Protect reconstituted solution from light; may store in original vial up to 12 hours at room temperature (25°C/77°F) 1

Dilution for Adults:

• Add appropriate volume of reconstituted micafungin into 100 mL of 0.9% Sodium Chloride Injection or 5% Dextrose Injection 1
• Final concentration should be between 0.5-4 mg/mL 1

Dilution for Pediatric Patients:

• Calculate total dose in mg by multiplying recommended pediatric dose (mg/kg) by patient weight 1
• Ensure final concentration is between 0.5-4 mg/mL 1
• For concentrations >1.5 mg/mL, must use central catheter 1

Storage Requirements

The combined storage time of reconstituted solution in the vial and diluted solution in the infusion bag must not exceed 12 hours at room temperature from time of reconstitution. 1

• This 12-hour limit includes storage of reconstituted solution, storage of diluted solution, AND duration of infusion 1
• Protect both reconstituted and diluted solutions from light (though covering infusion tubing is not necessary) 1
• Discard all partially used vials 1

Standard Dosing Regimens

For Invasive Candidiasis/Candidemia (Adults):

• 100 mg IV daily is the recommended dose for treatment of candidemia, acute disseminated candidiasis, Candida peritonitis, and abscesses 2, 3
• Continue for at least 2 weeks after documented clearance of Candida from bloodstream AND resolution of symptoms 2, 3

For Esophageal Candidiasis (Adults):

• 150 mg IV daily for treatment, particularly for fluconazole-refractory disease 2, 3, 4
• Continue for 14-21 days 2

For Prophylaxis (Adults):

• 50 mg IV daily for prophylaxis in hematopoietic stem cell transplant recipients 3
• Continue throughout period of neutropenia and high risk 3

Pediatric Dosing:

• For prophylaxis in children ≥1 year: 50 mg/m² per day (day 1: 70 mg/m²), maximum 70 mg per day 3
• For children 3-12 months: 50 mg/m² per day 3
• For infants <3 months: 25 mg/m² per day 3

Special Population Considerations

Neutropenic Patients:

• Use 100 mg IV daily for treatment of candidemia in neutropenic adults 3
• Continue for at least 2 weeks after bloodstream clearance AND resolution of neutropenia and symptoms 3
• For esophageal candidiasis in neutropenic patients: 150 mg IV daily 3

Critically Ill/Septic Patients:

• Standard dose of 100 mg IV daily is appropriate for severe sepsis with possible abdominal source 4
• Echinocandins including micafungin are preferred first-line agents in critically ill patients 4
• Surgical intervention is strongly recommended in addition to antifungal therapy for intra-abdominal candidiasis 4

Patients on CRRT:

• No dose adjustment is required for patients on continuous renal replacement therapy; use standard 100 mg IV daily dose 5
• For indications requiring higher doses, 150 mg daily can be used regardless of CRRT status 5

Critical Management Considerations

Monitoring Requirements:

• Perform dilated funduscopic examinations within first week after recovery from neutropenia to detect chorioretinitis 3
• Monitor for clinical response and clearance of Candida from bloodstream 4, 5
• Monitor liver function tests, as hepatic abnormalities can occur 1
• Monitor renal function tests, as elevations in BUN and creatinine have been reported 1
• Monitor for hemolysis or hemolytic anemia during therapy 1

Source Control:

• Remove central venous catheters when feasible in patients with candidemia 5
• Ensure appropriate surgical drainage/debridement for intra-abdominal candidiasis 5

Common Pitfalls to Avoid

• Never delay initiating appropriate antifungal therapy in critically ill patients, as mortality approaches 100% in septic shock without adequate treatment within 24 hours 4
• Do not prematurely discontinue therapy; failing to continue for at least 2 weeks after blood culture clearance is a common error 4, 5
• Avoid premature switching to fluconazole before confirming species identification and susceptibility, especially in critically ill patients 4, 5
• Do not infuse faster than 1 hour, as this increases risk of histamine-mediated reactions 1
• Do not use concentrations >1.5 mg/mL via peripheral IV; must use central catheter 1

Contraindications and Hypersensitivity

• Micafungin is contraindicated in persons with known hypersensitivity to micafungin, any component, or other echinocandins 1
• Discontinue immediately if anaphylaxis or anaphylactoid reactions occur 1