Caspofungin Amphotericin

Twenty percent of HIV-infected patients develop fluconazole-resistant Candida albicans isolates after repeated exposure to fluconazole.33 To treat fluconazole-resistant oropharyngeal candidiasis, daily itraconazole for 2 to 4 weeks may be used. Oral itraconazole solution exhibits a mycological cure rate of 88% and a clinical cure rate of 97% in immunocompromised patients.34 Fluconazole-resistant esophageal candidiasis should be treated with intravenous amphotericin B or caspofungin. 

If a patient is non-neutropenic and has never received prior azole therapy, fluconazole 800 mg/day is an appropriate first-line therapy for invasive candidiasis until identification of the Candida isolate. Amphotericin B deoxycholate 0.7 mg/kg per day or caspofungin 70 mg on day 1, then 50 mg/day, voriconazole, or a lipid amphotericin B formulation are recommended as empiric therapy in patients with neutropenic fever. 

Mucocutaneous candidiasis is generally not life-threatening nor invasive and can be treated with topical azoles (clotrimazole troches), oral azoles (fluconazole, ketoconazole, or itraconazole), or oral polyenes (such as nystatin or oral amphotericin B). Orally administered and absorbed azoles (ketoconazole, fluconazole, or itraconazole solution), amphotericin B suspension, intravenous caspofungin, or intravenous amphotericin B are recommended for refractory or recurrent infections.20... 

Mora-Duarte J, Betts R, Rotstein R, et al. Comparison of caspofungin and amphotericin B for invasive candidiasis. N Engl J Med 2002 347 2020-2029. 

In patients who have failed initial therapy (i.e., salvage), liposomal amphotericin products, itraconazole, or the echinocandin caspofungin can be used. Itraconazole has a response rate of approximately 40%.100 Oral itraconazole exhibits erratic absorption the IV formulation is suspended in cyclodextrin, which is eliminated renally, and thus IV itraconazole should be avoided in patients with a creatinine clearance of less than 30 mL/minute (0.29 mL/s m2).103 Itraconazole also has negative inotropic cardiac effects and increases the serum concentrations of medications (e.g., cyclophosphamide, etopo-side, calcineurin inhibitors, and sirolimus). 

Caspofungin is indicated for treatment of invasive aspergillosis in patients who are refractory to or intolerant of other therapies such as amphotericin B. 

Suspected systemic mycotic infection leading to sepsis in neutropenic and critically ill patients should be empirically treated with parenteral amphotericin B or caspofungin, especially if the patient is clinically unstable. 

Invasive aspergillosis For the treatment of invasive aspergillosis in patients who are refractory to or intolerant of other therapies (ie, amphotericin B, lipid formulations of amphotericin B, itraconazole). Caspofungin has not been studied as initial therapy for invasive aspergillosis. 

Caspofungin is the first of a new class termed the echinocandins. It was approved in the US and in Europe in 2001. It shows activity against infections with Aspergillus and Candida, and works by inhibiting p(, 3)-D-Glucan of the fungal cell wall. Compared to amphotericin B, caspofungin seems to have a relatively low incidence of side-effects. 

The patient described in the case study underwent extensive surgical debridement, and fungal culture of intraoperative specimens were positive for Rhizopus sp, one of the agents of mucormycosis. The patient was subsequently treated with a prolonged course of therapy with liposomal amphotericin and caspofungin and subsequent chronic suppressive therapy with posaconazole. 

Diekema D3 et al Activities of caspofungin, itraconazole, posaconazole, ravuconazole, voriconazole, and amphotericin against 448 recent clinical isolates of filamentous fungi. 3 Clin Microbiol 2003 41 3623. [PMID 12904365]... 

Aspergillus species Voriconazole Amphotericin B, itraconazole, caspofungin... 

Candidiasis Intestinal tract, skin, mucous membranes (mouth, pharynx, vagina) Amphotericin B, fluconazole Caspofungin, flucytosine, itraconazole... 

Caspofungin is currently licensed only for salvage therapy in patients with invasive aspergillosis who have failed to respond to amphotericin B. Clinical studies indicate that caspofungin is active also against Candida species in the setting of mucocutaneous candidiasis and candidal bloodstream infections. 

Candida species, torulopsis species Amphotericin B, caspofungin Fluconazole, itraconazole... 

Caspofungin is a cyclic polypeptide that inhibits synthesis of the fungal cell wall. It can be used in systemic mycoses due to as-pergillus fungi when amphotericin B or itroconazole cannot be employed. It is given by infusion and causes various adverse effects. 

Arikan S, Loranzo-Chin M, Paetznick V, et al. In vitro synergy of caspofungin and amphotericin B against Aspergillus and Pusartum spp. Antimicrob Agents Chemother 2002 46(1) 245-247. 

Arathoon EG, Gotuzzo E, Noriega LM, Berman RS, DiNubile MJ, Sable CA. Randomized, double-blind, multicenter study of caspofungin versus amphotericin B for treatment of oropharyngeal and esophageal candidiases. Antimicrob Agents Chemother 2002 46(2) 45I-7. 

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