From the FDA Drug Label
1.2 Treatment of Candidemia and Other CandidaInfections The FDA drug label does not answer the question.
From the Research
Double antifungal therapy for candidemia is generally indicated in severe or complicated cases, and the recommended approach is to combine an echinocandin with either fluconazole or an amphotericin B formulation, as supported by the most recent study 1. The indication for double antifungal therapy includes patients with severe sepsis or septic shock, those with persistent candidemia despite appropriate initial therapy, cases involving Candida species with reduced susceptibility to a single agent, and in patients with deep-seated infections like endocarditis, osteomyelitis, or CNS involvement. Some key points to consider when implementing double antifungal therapy include:
- Starting with standard dosing of both agents, such as caspofungin 70mg loading dose followed by 50mg daily plus fluconazole 800mg loading dose followed by 400mg daily.
- Treatment duration should typically be 14 days after the first negative blood culture and resolution of symptoms.
- The rationale for combination therapy is the potential for synergistic effects, broader coverage against resistant strains, and more rapid clearance of the infection in critically ill patients. However, this approach should be reserved for specific scenarios as it increases the risk of adverse effects and drug interactions compared to monotherapy, as noted in studies such as 2 and 3. It's also important to consider the results of the most recent study 1, which compared the efficacy and safety of different antifungal agents for the treatment of candidemia, and found that caspofungin, rezafungin, and micafungin had higher rates of clinical and mycological responses. Additionally, the study 4 highlights the challenges in the clinical management of invasive candidiasis in critically ill patients, and the need for more data on the clinical relevance of lower echinocandin exposure in this population. Overall, the decision to use double antifungal therapy for candidemia should be based on a careful consideration of the individual patient's risk factors, the severity of the infection, and the potential benefits and risks of combination therapy, as supported by the most recent and highest quality evidence 1.