Is Fluconazole or an Echinocandin the Agent of Choice for Candidemia

Objective: Candidemia is among the most common nosocomial bloodstream infections and is associated with high mortality, increased length of hospital stay, and significant economic burden. The introduction of the echinocandins in the 2000s has expanded the armamentarium against Candida spp and provides therapeutic options that are effective, safe, and tolerable. Although the Infectious Diseases Society of America favors echinocandins as treatment for candidemia in selected settings (at least as initial therapy), there remain divergent opinions about whether an echinocandin or fluconazole is the preferred agent for candidemia, and clinical practice guidelines are in flux. In this review, the currently available laboratory and clinical data are summarized and critically evaluated.

Data sources: A MEDLINE search of the English language literature was performed using the search terms echinocandin, fluconazole, and candidemia. References of review articles and guidelines were also screened for inclusion.

Study selection and data extraction: Studies whose primary goal was to compare echinocandins with fluconazole were evaluated as well as studies that differentiated pharmacological and pharmacokinetic properties between agents.

Data synthesis: It is clear that echinocandins and fluconazole each have roles in the management of candidemia. Specific recommendations are provided that will hopefully optimize outcomes in candidemia while incorporating stewardship concepts of cost-effectiveness and limiting the emergence of resistance.

Conclusions: Despite the advantages brought by the echinocandins and fluconazole, outcomes among patients with candidemia remain suboptimal. Improved treatment of candidemia may ultimately be achieved by optimizing the use of antifungal agents rather than the development of new drugs.