Current Pharmacological Concepts for Wise Use of Echinocandins in the Treatment of Candida Infections in Septic Critically Ill Patients

Federico Pea

Disclosures

Expert Rev Anti Infect Ther. 2013;11(10):989-997. 

In This Article

Abstract and Introduction

Abstract

Candida infections represent challenging causes of severe sepsis and/or of septic shock in the critically ill patients. Knowledge of current pharmacological concepts may promote a more wise use of echinocandins in the management of Candida infections in this setting. Echinocandins have some advantages over azoles, both pharmacodynamically (rapid fungicidal activity, anti-biofilm activity, unmodified activity against Candida isolates with decreased susceptibility to azoles and anti-cytokine/anti-chemokine activity) and pharmacokinetically (low interindividual variability, low potential for drug–drug interactions), that may influence the timing and the choice of therapy of Candida diseases in the critically ill patients. However, concerns exist in regards to the feasibility of fixed dosing regimens of echinocandins in all of the different patient populations and in regards to the effectiveness of echinocandin monotherapy in some clinical settings. In presence of deep-seated infections, voriconazole or liposomal amphotericin B may be valuable alternatives or add-on therapy.

Introduction

Candida infections represent frequent and challenging causes of severe sepsis and/or of septic shock in the non-neutropenic critically ill patients, and are associated with considerable morbidity and mortality.[1–3] Fluconazole has represented the mainstay of treatment of Candida infections in the past decade. However currently, the echinocandins are the first-line antifungal agents which are recommended in this setting by both the guidelines of the Infectious Diseases Society of America (IDSA)[4] and those of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID).[5]

Knowledge of current pharmacological concepts may promote a more wise use of these antifungal agents in this setting, with the intent of both maximizing clinical cure rates and preserving the activity over time by avoiding the spread of echinocandin resistance.

There are several pharmacodynamic characteristics that support the primary role of echinocandins over fluconazole in the therapeutic management of severe Candida infections in the critically ill patients (Box 1).

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