Abstract
BACKGROUND: Current guidelines recommend the use of echinocandins, amphotericin B or fluconazole for the treatment of invasive candidiasis and candidemia. The objective of our study was to compare these agents through a systematic review of the literature and network meta-analysis of randomized controlled trials. METHODS: Three electronic databases (Medline, PubMed, and the Cochrane Database of Systematic Reviews) were searched from database inception to January 1 2019. Randomized controlled trials that compared triazoles, echinocandins and/or amphotericin B (either in lipid formulation or deoxycholate form) for the treatment of invasive candidiasis or candidemia were included. Among included studies, treatment success was collected as the primary outcome and was assessed by a random effect network meta-analysis using Bayesian estimation methods. A sensitivity analysis was performed for all patients with candidemia. RESULTS: Eleven randomized controlled trials met the study inclusion criteria. Of the 2,475 patients included from these trials, 684 received an echinocandin, 855 received amphotericin B and 936 received a triazole. Echinocandins were associated with the highest rate of treatment success when compared with amphotericin B (OR 1.40, 95% CI 1.02–1.93) and the triazoles (OR 1.80, 95% CI 1.32–2.51). Similarly, in the pre-specified analysis of candidemic patients, echinocandins were also more effective overall than amphotericin B (OR 1.25, 95% CI 0.84–1.87) and triazoles (OR 1.66, 95% CI 1.16–2.44). Patients treated with triazoles had a lower rate of treatment success than amphotericin B in the overall (OR 0.78, 95% CI 0.60–1.01) and candidemia sensitivity analyses (OR 0.76, 95% CI 0.56–1.01) Rank probability analysis favored echinocandins as the most effective treatment choice 98% of the time. CONCLUSION: In our meta-analysis comparing treatment strategies for severe Candida infections, the echinocandins had the highest rate of treatment success compared with both amphotericin B and triazoles. Echinocandins should be considered as first-line agents in the treatment of invasive candidiasis and candidemia. Further research is needed to determine the minimum duration of echinocandin treatment prior to using step-down therapy. DISCLOSURES: All authors: No reported disclosures.