Current pharmacological concepts for wise use of echinocandins in the treatment of Candida infections in septic critically ill patients

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.

Keywords::

• candidemia
• candidiasis
• clinical pharmacology
• critically ills
• echinocandins

Financial & competing interests disclosure

The author has been in the speakers’ bureau of Gilead, MSD and Pfizer, and has been a consultant for Pfizer. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • The pharmacodynamic and pharmacokinetic properties support the primary role of the echinocandins in the treatment of Candida infections in critically ill patient with severe sepsis or with septic shock.

• • Concerns on echinocandin monotherapy exist when in presence of deep-seated Candida infections.

• • In these cases, voriconazole or liposomal amphotericin B may be valuable alternatives or add-on therapies.

• • De-escalation from an echinocandin to fluconazole should be applied in septic critically ill patients when achieving clinical stability.

Notes