De-escalation from micafungin is a cost-effective alternative to traditional escalation from fluconazole in the treatment of patients with systemicCandidainfections

Abstract

De-escalation from micafungin may improve clinical outcomes and overall survival, particularly among patients with fluconazole-resistant Candida strains. De-escalation from initial treatment with micafungin is a cost-effective alternative to escalation from a UK NHS perspective, with a differential cost per QALY below the 'willingness-to-pay' threshold of £30,000.

Treatment of invasive candidiasis: between guidelines and daily clinical practice

“…De-escalation strategy (initial treatment with echinocandins, followed by fluconazole when possible) has been proved to reduce mortality and improve outcome of IC/C with a significant cost saving, compared to escalation strategy (initial treatment with fluconazole) [36].…”

Cost Effectiveness of Candida Polymerase Chain Reaction Detection and Empirical Antifungal Treatment among Patients with Suspected Fungal Peritonitis in the Intensive Care Unit

“…Many studies on the economic management of invasive candidiasis are actually cost-effectiveness studies that have assessed the role of echinocandins for the empirical treatment of candidemia [24,25,[45][46][47][48][49]. Few studies have evaluated the economic impact of rapid diagnostic testing for this pathology [30,[50][51][52].…”

&quot;De-escalation&quot; strategy using micafungin for the treatment of systemic <em>Candida</em> infections: budget impact in France and Germany

“…A budget impact model, based on the cost-effectiveness model used by Masterton et al, 22 was used to compare a de-escalation strategy using micafungin as initial treatment to an escalation strategy in which patients initially received fluconazole ( Figure S1 ). Ethical approval for the model was not required.…”

“… 21 Nevertheless, fluconazole has traditionally often been regarded as the preferred first-line antifungal therapy in clinical practice because of its demonstrated efficacy against C. albicans and low acquisition costs. 9 In such instances, treatment is switched to a broad-spectrum antifungal agent such as an echinocandin only if Candida isolates are subsequently identified as non- albicans species or fluconazole resistant, a strategy known as “escalation.” 22 However, it has been shown that inappropriate antifungal therapy, such as treatment delay or incorrect dosing, increases mortality, hospital length of stay and hospital costs. 6 For example, a retrospective analysis of candidemia in an Italian hospital showed that 30-day crude mortality was ~20% in patients receiving appropriate antifungal therapy within 48 hours, increasing to 27%–33% with administration of antifungals after 48–72 hours, 53%–56% after 72–96 hours, and 57%–60% after >96 hours; when no antifungal treatment was administered, mortality reached 71%–75%.…”

“… 23 Given that fluconazole-resistant isolates account for an increasing proportion of SCIs, prompt initiation of broad-spectrum antifungal treatment is likely to benefit patient outcomes. Indeed, a recent analysis comparing de-escalation from the echinocandin, micafungin, to escalation from fluconazole in the treatment of patients with SCI 22 found the former approach to be cost-effective from a UK National Health Service perspective. As France and Germany are two of the most populous countries in Europe, 24 we now describe an evaluation of the budget impact of the de-escalation strategy (initial micafungin treatment switching to fluconazole if isolates are fluconazole sensitive) compared with the escalation strategy (initial fluconazole with switching to micafungin if isolates are fluconazole resistant) in these two countries.…”