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Caspofungin for Preventive and Preemptive Therapy of Invasive Candidiasis

Summary and Comment |
April 16, 2014

Caspofungin for Preventive and Preemptive Therapy of Invasive Candidiasis

  1. Neil M. Ampel, MD

In a multicenter trial, caspofungin was not superior to placebo for preventing invasive candidiasis.

  1. Neil M. Ampel, MD

Invasive candidiasis (IC) is the third most common bloodstream infection in the intensive care unit (ICU). Although targeted prophylaxis has been shown to be useful in certain populations, no large or multicenter trials have been performed to examine its efficacy or safety in the ICU setting. Earlier studies have established clinical prediction rules that identify patients at risk for IC, and the use of serum levels of the fungal cell wall component (1,3)-β-d-glucan (BG) could identify those in need of preemptive antifungal therapy.

Now, researchers in the Mycoses Study Group have reported the results of a manufacturer-supported, phase IV, randomized, double-blind, placebo-controlled trial of caspofungin prophylaxis in adults at high risk for IC, followed by BG-directed preemptive therapy for those who developed proven or probable IC. The study was conducted in 15 ICUs in the U.S. between August 2007 and March 2010.

In the prophylaxis portion of the study, which involved 186 participants who did not have an active invasive fungal infection at enrollment, the incidence of proven or probable IC was 9.8% for caspofungin compared with 16.7% for placebo (P=0.14). Among the 219 patients evaluable for the preemptive portion of the study (i.e., all patients included in the prophylaxis analysis, plus those excluded because they were retrospectively found to have IC at baseline), the incidence of proven or probable IC was 18.8% for caspofungin versus 30.4% for placebo (P=0.04). The incidence of adverse events was similar between the two study groups.

Comment

Although this trial did not demonstrate a benefit for caspofungin as prophylaxis, it did serve to demonstrate the feasibility and value of targeting specific high-risk patients for preemptive antifungal therapy and can serve as a model for future studies.

  • Disclosures for Neil M. Ampel, MD at time of publication Editorial boards Medical Mycology Leadership positions in professional societies Coccidiodomycosis Study Group (President-Elect)

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