The Journal of antimicrobial chemotherapy · 2026
Evaluation of an early step-down (≤5 days) strategy from echinocandins to azole therapy for the treatment of invasive candidiasis.
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Albanell-Fernández M, Tuset M, Vergara A, Villanueva M, Barrantes-González M, Bodro M, Soriano A, Herrera S
Аннотация
BACKGROUND: Invasive candidiasis (IC) carries high mortality; although guidelines recommend echinocandins followed by de-escalation (DES) to azoles in stable patients, the optimal timing, particularly for early (≤5 days) step-down, remains uncertain due to limited prospective evidence. This study evaluates the safety and outcomes of early (≤5 days) antifungal de-escalation (DES) versus standard therapy.
METHODS: Single-centre prospective study during 17 months in adults with candidemia or intra-abdominal candidiasis (IAC) receiving initial echinocandin therapy. Early (≤5 days) DES was compared with continued echinocandin therapy (non-DES). The primary outcome was 30-day global response; secondary outcomes included mortality at end of treatment (EoT), recurrence, length of stay, microbiological outcomes and antifungal consumption/costs. Inverse probability of treatment weighting (IPTW) was applied to adjust for baseline differences between groups.
RESULTS: Of 152 screened patients, 114 with IC (80 candidemia, 34 IAC) were included; 55.3% underwent DES, mainly to fluconazole (95.2%), at a median of 4 days. The 30-day global response was higher with DES but not statistically significant (60.3% versus 45.1%, P = 0.105). However, DES was associated with higher clinical success at EoT (79.4% versus 58.8%, P = 0.017) and lower EoT mortality (11.1% versus 29.4%, P = 0.014). After IPTW adjustment, DES was not associated with improved 30-day global response. In candidemia, DES improved 30-day response (65.1% versus 43.2%, P = 0.049), whereas no differences were observed in IAC. Early DES reduced antifungal costs by 77.4% per /candidemia episode.
CONCLUSIONS: Early DES in clinically stable IC patients with source control was safe and not associated with worse outcomes, supporting its use in stewardship programmes.
METHODS: Single-centre prospective study during 17 months in adults with candidemia or intra-abdominal candidiasis (IAC) receiving initial echinocandin therapy. Early (≤5 days) DES was compared with continued echinocandin therapy (non-DES). The primary outcome was 30-day global response; secondary outcomes included mortality at end of treatment (EoT), recurrence, length of stay, microbiological outcomes and antifungal consumption/costs. Inverse probability of treatment weighting (IPTW) was applied to adjust for baseline differences between groups.
RESULTS: Of 152 screened patients, 114 with IC (80 candidemia, 34 IAC) were included; 55.3% underwent DES, mainly to fluconazole (95.2%), at a median of 4 days. The 30-day global response was higher with DES but not statistically significant (60.3% versus 45.1%, P = 0.105). However, DES was associated with higher clinical success at EoT (79.4% versus 58.8%, P = 0.017) and lower EoT mortality (11.1% versus 29.4%, P = 0.014). After IPTW adjustment, DES was not associated with improved 30-day global response. In candidemia, DES improved 30-day response (65.1% versus 43.2%, P = 0.049), whereas no differences were observed in IAC. Early DES reduced antifungal costs by 77.4% per /candidemia episode.
CONCLUSIONS: Early DES in clinically stable IC patients with source control was safe and not associated with worse outcomes, supporting its use in stewardship programmes.