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Invasive candidiasis is an important cause of morbidity and mortality among hospitalized patients. Current therapeutic options include amphotericin B, echinocandins such as anidulafungin, and azoles such as fluconazole. In a recent manufacturer-sponsored, randomized, multicenter trial, investigators compared anidulafungin with fluconazole, both administered for ≥14 days (intravenously for the initial ≥10 days), for the treatment of invasive candidiasis. The main endpoint was global response at the end of intravenous therapy. Successful treatment was defined as resolution of signs and symptoms of invasive candidiasis and eradication of candida species present at baseline.
Two hundred forty-five patients who received ≥1 dose of the study medication and had a positive culture for candida species ≤96 hours before enrollment were included in the modified intent-to-treat analysis. Among these patients, 89% had candidemia only; Candida albicans was isolated in 62%. Treatment was successful in 96 of 127 anidulafungin recipients, compared with 71 of 118 fluconazole recipients (P=0.01). However, when data from the center that contributed the largest number of cases (25) were dropped from the analysis, anidulafungin was statistically noninferior to fluconazole, rather than superior. Anidulafungin recipients showed higher response rates for every candida species except C. parapsilosis.
Reboli AC et al. Anidulafungin versus fluconazole for invasive candidiasis. N Engl J Med 2007 Jun 14; 356:2472-82.
Sobel JD and Revankar SG. Echinocandins — First-choice or first-line therapy for invasive candidiasis? N Engl J Med 2007 Jun 14; 356:2525-6.
Comment
Although anidulafungin showed superiority in evaluations of the entire study cohort, the authors advise caution in interpreting this finding because they could not rule out a center effect. Editorialists note that, whatever the results with echinocandins in candidemia studies, fluconazole should not be abandoned yet; it is far less expensive than these agents and may have efficacy for forms of candidiasis that they do not. Moreover, we have no evidence showing therapeutic differences among the three echinocandins now available — caspofungin, micafungin, and anidulafungin.