67 Recently, a similar trend was reported for ICU patients in a single-centre observational study,68 and has been described in a review of published data predominantly originating from the US.69 Concerning echinocandins, selection of caspofungin-resistant strains has been observed in isolated cases,70 and an increase of C. parapsilosis candidaemia over a 5-year period in parallel to increasing use of caspofungin learn more use was reported from one large tertiary care centre.71 In general, however, current data do not support the notion of broad-scale species shifts or strain selection as a result of pressure exerted by the therapeutic use of echinocandins.

All the same, for convenience selleck products and cost reasons a switch to oral or intravenous treatment with an azole antifungal may appear desirable after stabilisation of the patient. Randomised clinical trials involving echinocandins required 10 days of initial therapy before a switch to an oral agent (usually fluconazole) was allowed.46,48,49 In these studies, 26%, 25% and 21% of the patients initially randomised to a standard-dose echinocandin switched to oral fluconazole after >10 days of therapy. Further prerequisites were confirmed negative blood cultures, defervescence for at least 24 h, improvement of clinical status and demonstration of susceptibility of the initial isolate to the oral agent of choice (fluconazole,

voriconazole). We should add adequate gastrointestinal function to assure crotamiton enteral absorption. A switch earlier than 10 days after initiation of therapy is feasible in individual cases, but it must be emphasised that this procedure is not supported by evidence from randomised

trials. Davis et al. [72] presented a two-period monocentric study comparing a retrospective period 1 with unregulated use of echinocandins (caspofungin or micafungin) for IC vs. an interventional period 2 involving formal in-house recommendations for step down by day 5 from intravenous anidulafungin to an oral azole (fluconazole or voriconazole; the latter to be used in cases with documented C. glabrata infection or unknown species) if certain criteria for oral treatment had been met (negative blood cultures, functional gastrointestinal tract, haemodynamic stability and improved clinical profile including leucocyte counts and body temperature). The rate of patients receiving oral step-down therapy was significantly increased in period 2, the duration of intravenous therapy and the duration of total therapy was decreased, whereas the clinical success rate remained unchanged and hospital mortality showed no significant difference. While the use of historical controls and potential educative effects of the intervention may have biased the results, these data suggest that an early step-down to an oral azole may be feasible in certain patients without compromising outcomes.