From the Guidelines
Fungemia treatment should be initiated with an echinocandin, such as caspofungin 70mg loading dose followed by 50mg daily, micafungin 100mg daily, or anidulafungin 200mg loading dose followed by 100mg daily, as the first-line treatment. This recommendation is based on the strongest and most recent evidence from the Infectious Diseases Society of America (IDSA) guidelines, which suggest that echinocandins have fungicidal activity against most Candida species and lower toxicity compared to amphotericin B formulations, while providing coverage against increasingly common azole-resistant strains 1.
Key Considerations
- For patients who are less critically ill and who have no recent azole exposure, fluconazole 800mg loading dose followed by 400mg daily can be used as an alternative treatment 1.
- Treatment should continue for at least 2 weeks after documented clearance of Candida from the bloodstream, provided neutropenia and symptoms attributable to candidemia have resolved 1.
- Source control is essential, including removal of infected catheters or draining abscesses, and follow-up blood cultures should be obtained to document clearance of fungemia 1.
- Antifungal susceptibility testing guides therapy adjustments, and echinocandins are preferred for initial therapy because they have fungicidal activity against most Candida species and lower toxicity compared to amphotericin B formulations, while providing coverage against increasingly common azole-resistant strains 1.
Special Considerations
- For infections due to C. krusei, an echinocandin, lipid formulation AmB, or voriconazole is recommended 1.
- For patients with candidemia and a short-term CVC, the catheter should be removed and the catheter tip sent for culture, or alternatively, the catheter can be exchanged over a guidewire and catheter cultures performed 1.
- Antifungal therapy is recommended for all cases of CRBSI due to Candida species, including cases in which clinical manifestations of infection and/or candidemia resolve after catheter withdrawal and before initiation of antifungal therapy 1.
From the FDA Drug Label
The dosage and duration of caspofungin acetate for injection treatment for each indication are as follows: Candidemia and Other Candida Infections Administer a single 70-mg loading dose on Day 1, followed by 50 mg once daily thereafter. Duration of treatment should be dictated by the patient's clinical and microbiological response In general, continue antifungal therapy for at least 14 days after the last positive culture.
Fungemia treatment with caspofungin acetate for injection is administered as a single 70-mg loading dose on Day 1, followed by 50 mg once daily thereafter. The duration of treatment should be based on the patient's clinical and microbiological response, and antifungal therapy should be continued for at least 14 days after the last positive culture 2.
From the Research
Fungemia Treatment Options
- The treatment of fungemia, a serious fungal infection, can be achieved through various antifungal medications, including micafungin, caspofungin, liposomal amphotericin B, and voriconazole 3, 4.
- Micafungin, an echinocandin, has been shown to be effective in treating invasive candidiasis and oesophageal candidiasis, with a pharmacokinetic profile that allows for once-daily treatment and minimal drug-drug interactions 3.
- Caspofungin and liposomal amphotericin B have also been used in combination to treat refractory invasive mycosis, with favorable responses observed in patients 4.
- The activity of various antifungal agents, including amphotericin B, anidulafungin, caspofungin, micafungin, posaconazole, and voriconazole, has been evaluated against Candida albicans with decreased susceptibility to fluconazole, with all isolates found to be highly susceptible to amphotericin B and echinocandins 5.
- Combination therapy with antifungal agents, such as AmBisome and voriconazole, has been shown to be effective in treating experimental murine central nervous system aspergillosis, with enhanced activity demonstrated when used in combination 6.
Antifungal Medications
- Micafungin: effective against invasive candidiasis and oesophageal candidiasis, with a favorable pharmacokinetic profile 3.
- Caspofungin: used in combination with liposomal amphotericin B to treat refractory invasive mycosis, with favorable responses observed in patients 4.
- Liposomal amphotericin B: used in combination with caspofungin to treat refractory invasive mycosis, and as a monotherapy to treat experimental murine central nervous system aspergillosis 4, 6.
- Voriconazole: used in combination with AmBisome to treat experimental murine central nervous system aspergillosis, with enhanced activity demonstrated when used in combination 6.