Older Antifungal Still a Good Choice Against Tough Infections

Fluconazole usually performs as well as newer, more expensive drugs, study finds

WEDNESDAY, June 13, 2007 (HealthDay News) -- An older, cheaper medication to treat potentially deadly fungal infections may work just as well as a newer drug in most cases, a new study shows.

Fungal infections may be a non-issue for most healthy people but they can be life-threatening for people who are already ill and for babies who are born pre-term and tiny.

The authors of the study predict that more health-care providers will still turn to the newer medicines, known as echinocandins, rather than the older one, fluconazole.

"I think we will see more use of echinocandins up front, especially in critically ill patients, and fluconazole or another one in that class when the patient has responded and turned a corner," said Dr. Annette C. Reboli, lead author of the study. She is a professor of medicine at the University of Medicine and Dentistry of New Jersey/Robert Wood Johnson Medical School and head of the infectious diseases division at Cooper University Hospital, both in Camden.

Others felt the findings would not affect practice in any meaningful way.

"The drugs are about equal. Anidulafungin [an echinocandin] is maybe a hair better but not statistically so," said Dr. Douglas L. Hurley, professor of internal medicine at Texas A&M Health Science Center and an infectious disease physician at Scott & White Hospital. "In the main, fluconazole will work. This is a bigger study so it nails it down. It won't ever have to be repeated."

The study findings are published in the June 14 issue of the New England Journal of Medicine.

A second study in the same issue of the journal found that fluconazole was effective for preventing fungal infections in premature babies.

The first compound used to treat candidiasis (yeast infection) was amphotericin B, which was effective but was limited by side effects.

Over the years, less toxic alternatives were developed such as fluconazole and a newer class of drugs known as echinocandins, one of which is anidulafungin.

Although expert guidelines issued in 2004 state that all of the above classes of drugs are appropriate to treat candidiasis, in reality, fluconazole was the one most prescribed.

For the new study, adults with invasive candidiasis were randomly assigned to receive anidulafungin or fluconazole. At the end of the intravenous phase of therapy, treatment was successful in 75.6 percent of patients taking anidulafungin, compared with 60.2 percent of those taking fluconazole. Side effects were similar in the two groups.

"The trial certainly showed non-inferiority but, in certain situations, anidulafungin was better," Reboli said.

An accompanying editorial stated that there is "absolutely no justification for abandoning fluconazole, given its safety, overall efficacy and low cost." While the price of echinocandins has fallen, it is still higher than fluconazole, the editorial said.

A second study, conducted in Italy, found that giving fluconazole prophylactically to babies born preterm and weighing less than about 3 pounds at birth reduced the incidence of colonization and invasive candida infection.

Among babies receiving fluconazole, 7.7 percent of those taking 3 milligrams and 9.8 percent of those taking 6 milligrams had fungal colonization, vs. 29.2 percent in the placebo group.

Only 2.7 percent of infants in the 6 milligram group and 3.8 percent of those in the 3 milligram group developed invasive fungal infection, compared with 13.2 percent in the placebo group. Death rates were similar among the different groups.

"Again, this probably will not change much of what's being done," Hurley said. "The babies who got fluconazole had less colonization with candida and thence less invasive disease than those getting the placebo, but there was no difference in overall mortality."

More information

Get a primer on candidiasis from the U.S. National Library of Medicine.

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