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Abstract
Background: Caspofungin is approved in the United States for empiric antifungal therapy for persistent
febrile neutropenia (FN). There are limited data about the use of other echinocandins
in this setting.
Objective: After a formulary change, we retrospectively evaluated the safety and effectiveness
of caspofungin and micafungin as empiric antifungal therapy for FN at Brigham and
Women's Hospital (Boston, Massachusetts).
Methods: This was a retrospective, observational, sequential cohort study. We identified patients
who had received ≥2 doses on concurrent days of either caspofungin (between November
2005 and October 2006) or micafungin (between November 2006 and October 2007) for
empiric FN therapy. Patients were included for analysis if they were neutropenic (absolute
neutrophil count <500 cells/μL) and febrile (temperature ≥100.5°F [≥38°C]). Patients
without previous exposure to an echinocandin were included; those included in the
caspofungin cohort were excluded from the micafungin cohort. Those who had previously
received another systemic antifungal agent for FN therapy (except fluconazole for
mucosal candidiasis) were excluded. Patients were followed through hospital discharge.
Outcomes analyzed were successful treatment of baseline invasive fungal disease (IFD),
incidence of breakthrough IFD, overall mortality, and discontinuation because of adverse
events (AEs). IFD was diagnosed and classified according to current European Organization
for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group
and the National Institute of Allergy and Infectious Diseases Mycoses Study Group
Consensus Group criteria.
Results: Three hundred twenty-three patients met inclusion criteria (caspofungin, n = 149;
micafungin, n = 174). Median age was 49 years in both the caspofungin and micafungin
groups; 80 (53.7%) and 99 (56.9%) patients in each group, respectively, were men.
Fluconazole prophylaxis had been administered to 30 patients (20.1%) treated with
caspofungin and 21 patients (12.1%) treated with micafungin. Caspofungin was administered
at 70 mg for one dose, followed by 50 mg daily; micafungin was administered at 100
mg daily. The median duration of therapy and of hospitalization were 10 days and 29
days, respectively, with caspofungin, and 9 days and 28 days with micafungin (both,
P = NS between groups). Twelve patients (8.1%) in the caspofungin cohort and 13 (7.5%)
in the micafungin cohort died during the study period (P = NS). There were 3 cases (2.0%) of baseline IFD in the caspofungin cohort and 6
(3.4%) in the micafungin cohort (P = NS); 6 were successfully treated (caspofungin, 2 [1.3% of entire group]; micafungin,
4 [2.37% of entire group]; P = NS). Breakthrough IFD was diagnosed in 16 patients (10.7%) receiving caspofungin
and 21 (12.1%) receiving micafungin (P = NS). AEs requiring echinocandin discontinuation were uncommon (caspofungin, 2 cases
of rash and 1 anaphylactoid infusion reaction [2.0%]; mica-fungin, 1 liver function
test elevation ≥5 times the upper limit of normal and 1 maculopapular rash [1.1%];
P = NS).
Conclusion: Micafungin, as empiric antifungal therapy for persistent FN, did not appear to differ
significantly from caspofungin in terms of safety profile or efficacy in the adult
patients included in this sequential cohort analysis at one institution.
Key words
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Article info
Publication history
Accepted:
March 10,
2010
Footnotes
Results from this study were presented in part at the Annual Interscience Conference on Antimicrobial Agents and Chemotherapy and Annual Meeting of the Infectious Diseases Society of America joint meeting, October 27, 2008, Washington, DC.
Identification
Copyright
© 2010 Excerpta Medica Inc. Published by Elsevier Inc. All rights reserved.
