Раннее снижение терапии эхинокандинами на азолы безопасно и снижает расходы при инвазивном кандидозе

TOPLINE Early antifungal de-escalation (DES) from an echinocandin to an azole within 5 days was safe and not associated with worse 30-day outcomes in clinically stable patients with invasive candidiasis who had adequate source control. It also reduced drug costs by more than half, particularly among those with candidemia. METHODOLOGY - Researchers conducted a 17-month prospective study at a tertiary hospital in Barcelona, Spain, to compare clinical outcomes of early step-down therapy from an echinocandin to an azole within 5 days vs continued echinocandin therapy. - They enrolled 114 adults (median age, 66.5 years) with invasive candidiasis, including 80 with candidemia and 34 with intra-abdominal candidiasis (IAC). - Participants initially received echinocandin therapy (micafungin 100 mg/d or anidulafungin 200 mg loading dose followed by 100 mg/d). Of 114 patients, 63 (55.3%) underwent early DES to an azole — mainly fluconazole (in 95.2% of cases) — at a median of 4 days (DES group), while 51 continued echinocandin therapy (non-DES group). - The primary outcome was 30-day global response; secondary outcomes included end-of-treatment (EOT) clinical response, EOT mortality, 30-day recurrence, length of stay, microbiological outcomes, and antifungal consumption and costs. TAKEAWAY - The 30-day global response was numerically higher with DES but not statistically significant in the overall cohort (60.3% vs 45.1%; P = .105). - In the overall cohort, DES was associated with higher EOT clinical success (79.4% vs 58.8%; P = .017) and lower EOT mortality (11.1% vs 29.4%; P = .014) than non-DES. - In patients with candidemia, DES was associated with improved 30-day global response (65.1% vs 43.2%; P = .049) and EOT clinical success rates (83.7% vs 59.5%; P = .015), as well as lower EOT mortality (9.3% vs 32.4%; P = .010). No significant differences in outcomes were observed between the DES and non-DES groups in patients with IAC, but rates of persistent positive culture were substantially higher in patients with IAC (33.3%) than in those with candidemia (7.7%). - In the overall cohort, 30-day recurrence was lower in the DES group than in the non-DES group (6.8% vs 13.8%), and median length of stay was similar between groups (40 vs 42 days). - Early step-down reduced antifungal cost by 77.4% per candidemia episode, or €3146 per episode. IN PRACTICE “In adult patients with IC [invasive candidiasis] who were clinically stable and had adequate source control, early DES (≤ 5 days) was safe and not associated with worse clinical outcomes, including 30-day mortality, recurrence, or persistence. Step-down to fluconazole enables targeted therapy, reduces selective pressure, and decreases antifungal costs by more than half,” the authors of the study wrote. SOURCE This study was led by M. Albanell-Fernández, Pharmacy Service, Division of Medicines, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain. It was published online on July 31, 2026, in the Journal of Antimicrobial Chemotherapy. LIMITATIONS Although the study was conducted prospectively, the absence of randomization and blinding may have introduced selection bias. The planned sample size was not achieved, which potentially limited statistical power. The safety of DES in this high-risk population could not be assessed because of the small number of patients with neutropenia. DISCLOSURES Albanell-Fernández received a grant from the Hospital Clinic of Barcelona to support this study. The authors disclosed having no conflicts of interest. This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.