Eraxis

Generic Name: Anidulafungin
Class: Echinocandins
VA Class: AM700
Chemical Name: 1 - [(4R,5R) - 4,5 - dihydroxy - N2 - [[4″ - (pentyloxy)[1,1′:4′,1″ - terphenyl] - 4 - yl]carbonyl] - l - ornithine] Echinocandin B
Molecular Formula: C58H73N7O17
CAS Number: CAS-166663-25-8

Introduction

Antifungal; echinocandin; lipopeptide synthesized from a fermentation product of Aspergillus nidulans.1 2 4 5 7

Uses for Eraxis

Candidemia and Other Invasive Candida Infections

Treatment of candidemia and certain other invasive Candida infections (intra-abdominal abscess, peritonitis).1 5 8 19 21 24 A drug of choice.21 24

For treatment of candidemia in nonneutropenic patients or for empiric treatment of suspected invasive candidiasis in such patients, IDSA recommends fluconazole or an echinocandin (caspofungin, micafungin, anidulafungin) for initial therapy;24 amphotericin B (conventional or lipid formulation) is the preferred alternative.24 An echinocandin may be preferred for initial treatment in those who have moderately severe to severe candidemia, are allergic to or intolerant of azole antifungals, have recently received an azole, or have or are likely to have infections caused by Candida glabrata or C. krusei.24 Fluconazole may be preferred for initial treatment in those who are less critically ill and have not recently received an azole and for infections caused by C. parapsilosis.24 If an echinocandin is used initially, transition to fluconazole is recommended for patients who are clinically stable and have isolates likely to be susceptible to fluconazole (e.g., C. albicans).24

For treatment of candidemia in neutropenic patients, IDSA recommends an echinocandin (caspofungin, micafungin, anidulafungin) or amphotericin B (a lipid formulation) for initial therapy;24 fluconazole is the preferred alternative in those who are less critically ill or have not recently received an azole;24 voriconazole can be used as an alternative when broader antifungal coverage is required.24 An echinocandin is preferred for C. glabrata infections;24 fluconazole or amphotericin B (a lipid formulation) is preferred for C. parapsilosis infections;24 an echinocandin, amphotericin B (a lipid formulation), or voriconazole is recommended for C. krusei infections.24 For initial empiric treatment of suspected invasive candidiasis in neutropenic patients, amphotericin B (a lipid formulation), caspofungin, or voriconazole is recommended;24 alternatives are fluconazole or itraconazole.24

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Safety and efficacy not established for treatment of endocarditis, osteomyelitis, or meningitis caused by Candida.1

Manufacturer states efficacy data are insufficient to date regarding use of anidulafungin for treatment of candidemia or other invasive Candida infections in neutropenic patients.1

Esophageal Candidiasis

Treatment of esophageal candidiasis.1 3 5 11 21 24 26 A drug of choice.21 24

Esophageal candidiasis requires treatment with a systemic antifungal (not a topical antifungal).24 26

IDSA recommends oral fluconazole as the preferred drug of choice for the treatment of esophageal candidiasis;24 if oral therapy is not tolerated, IV fluconazole, IV amphotericin B (conventional formulation), or an IV echinocandin (caspofungin, micafungin, anidulafungin) is recommended.24 For fluconazole-refractory infections, preferred alternatives are itraconazole oral solution, oral posaconazole, or IV or oral voriconazole;24 other alternatives are an IV echinocandin (caspofungin, micafungin, anidulafungin) or IV amphotericin B (conventional formulation).24

For treatment of esophageal candidiasis in HIV-infected adults and adolescents, CDC, National Institute of Health (NIH), and IDSA recommend IV or oral fluconazole as the preferred drug of choice and itraconazole oral solution as the preferred alternative.26 Other alternatives include an IV echinocandin (caspofungin, micafungin, anidulafungin), oral or IV voriconazole, oral posaconazole, or IV amphotericin B (conventional formulation).26 For refractory esophageal candidiasis, including fluconazole-refractory infections, itraconazole oral solution or oral posaconazole is preferred;26 alternatives include IV amphotericin B (conventional or lipid formulation), an IV echinocandin (caspofungin, micafungin, anidulafungin), or oral or IV voriconazole.26

Patients with frequent or severe recurrences of esophageal candidiasis, including HIV-infected patients, may benefit from long-term suppressive or maintenance therapy (secondary prophylaxis) with oral fluconazole or oral posaconazole; however, the potential for azole resistance should be considered.1 3 24 26 Echinocandins not included in recommendations for secondary prophylaxis of esophageal candidiasis.24 26 Patients with fluconazole-refractory esophageal candidiasis who responded to an echinocandin should receive voriconazole or posaconazole for secondary prophylaxis until antiretroviral therapy produces immune reconstitution.26

Oropharyngeal Candidiasis

Treatment of oropharyngeal candidiasis.21 24 26 Considered an alternative, not a drug of choice.24 26

IDSA recommends topical clotrimazole or topical nystatin for mild oropharyngeal candidiasis;24 oral fluconazole is recommended for moderate to severe disease.24 For refractory oropharyngeal candidiasis, including fluconazole-refractory infections, itraconazole oral solution, oral posaconazole, or oral voriconazole is recommended.24 An IV echinocandin (caspofungin, micafungin, anidulafungin) or IV amphotericin B (conventional formulation) also are recommended as alternatives for refractory infections.24

For treatment of oropharyngeal candidiasis in HIV-infected adults and adolescents, CDC, NIH, and IDSA recommend oral fluconazole as the preferred drug of choice for initial episodes;26 alternatives for initial episodes include topical clotrimazole or topical nystatin.26 For fluconazole-refractory infections, itraconazole oral solution or oral posaconazole is preferred;26 alternatives include IV amphotericin B (conventional or lipid formulation), an IV echinocandin (caspofungin, micafungin, anidulafungin), or oral or IV voriconazole.26

Patients with frequent or severe recurrences of oropharyngeal candidiasis, including HIV-infected patients, may benefit from long-term suppressive or maintenance therapy (secondary prophylaxis) with oral fluconazole or itraconazole oral solution; however, the potential for azole resistance should be considered.24 26 Echinocandins not included in recommendations for secondary prophylaxis of oropharyngeal candidiasis.24 26 Patients with fluconazole-refractory oropharyngeal candidiasis who responded to an echinocandin should receive voriconazole or posaconazole for secondary prophylaxis until antiretroviral therapy produces immune reconstitution.26

Eraxis Dosage and Administration

Administration

IV Administration

Administer by slow IV infusion.1 Do not administer by rapid IV injection.1

Do not admix or infuse concomitantly with other drugs.1

Reconstitution

Reconstitute 50- or 100-mg vials of lyophilized anidulafungin with 15 or 30 mL, respectively, of sterile water for injection to provide a solution containing 3.33 mg/mL.1

Dilution

Dilute total contents of the required number of reconstituted vials in 50, 100, or 200 mL of 5% dextrose injection or 0.9% sodium chloride injection as directed to provide an IV infusion solution containing 0.77 mg/mL.1 (See Table.)

Use strict aseptic technique since drug contains no preservative.1

Instructions for Diluting Reconstituted Vials of Anidulafungin1

Anidulafungin Dose Indicated

Number of Reconstituted Vials Required

Required Volume of Diluent (5% Dextrose Injection or 0.9% Sodium Chloride Injection)

Total Infusion Volume of 0.77-mg/mL Solution

Minimum Duration of Infusion (minutes)

50 mg

One 50-mg vial

50 mL

65 mL

45

100 mg

Two 50-mg vials or one 100-mg vial

100 mL

130 mL

90

200 mg

Four 50-mg vials or two 100-mg vials

200 mL

260 mL

180

Rate of Administration

Administer IV infusions at a rate not exceeding 1.1 mg/minute (1.4 mL/minute).1 More rapid infusion may increase risk of histamine-mediated reactions.1 (See Histamine-mediated Reactions under Cautions.)

Dosage

Adults

Candidemia and Other Invasive Candida Infections (Intra-abdominal Abscess, Peritonitis)
IV

A single 200-mg loading dose on day 1, followed by 100 mg once daily.1 21 24

Duration of treatment is based on clinical response.1 Manufacturer recommends anidulafungin be continued for at least 14 days after last positive culture.1 IDSA and others recommend that antifungal treatment for candidemia (without persistent fungemia or metastatic complications) be continued for 14 days after first negative blood culture and resolution of signs and symptoms of candidemia.21 24

Esophageal Candidiasis
IV

A single 100-mg loading dose on day 1, followed by 50 mg once daily is recommended by the manufacturer and some clinicians.1 21 IDSA recommends a single 200-mg loading dose on day 1, followed by 100 mg once daily.24

HIV-infected adults: A single 100-mg loading dose on day 1, followed by 50 mg once daily.26

Duration of treatment is based on clinical response.1 Manufacturer recommends a minimum of 14 days and at least 7 days following resolution of symptoms.1 IDSA and others recommend that antifungal treatment be continued for 14–21 days.21 24 26

Oropharyngeal Candidiasis
IV

Some clinicians recommend a single 100-mg loading dose on day 1, followed by 50 mg once daily.21 IDSA recommends a single 200-mg loading dose on day 1, followed by 100 mg once daily.24

HIV-infected adults: A single 100-mg loading dose on day 1, followed by 50 mg once daily.26

IDSA and others recommend that antifungal treatment be continued for 7–14 days.24 26

Special Populations

Hepatic Impairment

Dosage adjustment not required in adults with mild, moderate, or severe hepatic impairment (Child-Pugh class A, B, or C).1

Renal Impairment

Dosage adjustment not required.1 Not dialyzable; may administer without regard to dialysis timing.1 2 4 5 7 11

Geriatric Patients

Dosage adjustment not required in adults ≥65 years of age.1 7 11

Cautions for Eraxis

Contraindications

  • Known hypersensitivity to anidulafungin, other echinocandin antifungals (e.g., caspofungin, micafungin), or any ingredient in the formulation.1

Warnings/Precautions

Sensitivity Reactions

Hypersensitivity Reactions

Possible histamine-mediated symptoms (e.g., rash, urticaria, flushing, pruritus, dyspnea, hypotension).1 6 12 Reported infrequently when infusion rate does not exceed 1.1 mg/minute.1

Hepatic Effects

Abnormal liver function test results reported.1 Clinically important hepatic dysfunction, hepatitis, or worsening hepatic failure reported in patients with serious underlying conditions receiving multiple drugs concomitantly; causal relationship not established.1

If abnormal liver function test results occur, monitor for evidence of worsening hepatic function and evaluate benefits versus risks of continuing therapy.1

Selection and Use of Antifungals

Obtain specimens for fungal culture and other relevant laboratory studies (e.g., histopathology) prior to initiation of therapy.1 Therapy may be started pending results; adjust therapy as needed when results available.1

Specific Populations

Pregnancy

Category C.1

Lactation

Distributed into milk in rats; not known whether distributed into human milk.1 Use only if potential benefits outweigh risks.1

Pediatric Use

Safety and efficacy not established in pediatric patients.1

Has been used in a limited number of neutropenic children 2–17 years of age without unusual adverse effects.18

Some experts state data are insufficient to date to recommend use of anidulafungin for first-line treatment of invasive candidiasis or for treatment of esophageal or oropharyngeal candidiasis in children (including HIV-infected children).25

Common Adverse Effects

GI effects (diarrhea,1 nausea1 3 5 6 8 ), phlebitis/thrombophlebitis,3 5 6 hypokalemia,1 8 12 increased ALT,1 3 increased alkaline phosphatase,1 increased γ-glutamyltransferase (GGT, γ-glutamyl transpeptidase, GGPT),1 3 7 12 headache,1 3 5 6 8 rash,1 3 neutropenia.1 3 5 6

Interactions for Eraxis

Does not inhibit or induce and is not a substrate for CYP isoenzymes.1 5 6 7 9 11 27 28

Drugs Metabolized by Hepatic Microsomal Enzymes

Pharmacokinetic interactions unlikely with drugs metabolized by CYP isoenzymes 1A2, 2B6, 2C8, 2C9, 2C19, 2D6, 3A.1 7 28

Drugs Affecting or Affected by P-glycoprotein Transport

Not an inhibitor or substrate of the P-glycoprotein transport system; pharmacokinetic interactions unlikely.11 27 30

Specific Drugs

Drug

Interaction

Comments

Amphotericin B

No clinically important pharmacokinetic interactions1

In vitro evidence of additive antifungal effects against Candida, including C. albicans, C. glabrata, C. krusei, C. parapsilosis, C. tropicalis22

In vitro evidence of antagonism against some strains of Aspergillus flavus and A. terreus; in vitro evidence of synergism against some strains of A. fumigatus16

Anidulafungin dosage adjustment not necessary1

Clinical importance of in vitro studies unclear16 22

Fluconazole

In vitro evidence of additive or indifferent antifungal effects against C. albicans, C. glabrata; in vitro evidence of indifference against C. krusei, C. parapsilosis, C. tropicalis22

Clinical importance of in vitro studies unclear22

Flucytosine

In vitro evidence of additive or indifferent antifungal affects against C. albicans, C. glabrata, C. krusei, C. parapsilosis, C. tropicalis22

Clinical importance of in vitro studies unclear22

Immunosuppressive agents (cyclosporine, tacrolimus)

Cyclosporine: Increased anidulafungin AUC at steady state but no clinically important change in anidulafungin steady-state peak plasma concentrations; no effect on cyclosporine pharmacokinetics1 5 9 11

Tacrolimus: No clinically important pharmacokinetic interactions with oral tacrolimus1 14

Cyclosporine: Anidulafungin and cyclosporine dosage adjustments not necessary1 9 11

Tacrolimus: Anidulafungin and tacrolimus dosage adjustments not necessary1

Itraconazole

In vitro evidence of additive or indifferent antifungal effects against Candida, including C. albicans, C. glabrata, C. krusei, C. parapsilosis, C. tropicalis22

Synergistic or indifferent antifungal effects against Aspergillus; indifferent effects against Fusarium16

Clinical importance of in vitro studies unclear16

Ketoconazole

In vitro evidence of additive or indifferent antifungal effects against C. albicans, C. glabrata, C. krusei, C. parapsilosis; in vitro evidence of antagonism against C. tropicalis22

Clinical importance of in vitro studies unclear16

Rifampin

No clinically important pharmacokinetic interactions1 6 11

Anidulafungin dosage adjustment not necessary1

Voriconazole

No clinically important pharmacokinetic interactions with oral voriconazole1 7 17

Anidulafungin and voriconazole dosage adjustments not necessary1 7

Eraxis Pharmacokinetics

Absorption

Plasma Concentrations

Linear relationship between dose and peak plasma concentration and AUC.30 31

Steady state achieved on the first day after an IV loading dose.1

Distribution

Extent

Crosses placenta in rats and detected in rat fetal plasma;1 not known whether crosses placenta in humans.1

Distributed into milk of lactating rats;1 not known whether distributed into human milk.1

Plasma Protein Binding

>99%.1

Elimination

Metabolism

Slow chemical degradation at physiologic temperature and pH; metabolite exhibits no antifungal activity.1 5 6 7 12

Elimination Route

Eliminated principally in feces via the biliary tract.5 28 30 Following a single IV dose, 30% recovered in feces over 9 days (<10% as unchanged drug); <1% excreted in urine.1 5 7 28

Half-life

Distribution half-life is 0.5–1 hour;1 terminal elimination half-life is 27–52 hours.1 5 28

Special Populations

Geriatric adults: Median clearance in adults ≥65 years of age slightly less than that in younger adults; dosage adjustments not required.1

Hepatic impairment: Not metabolized in the liver;1 6 7 9 concentrations not increased in adults with mild, moderate, or severe hepatic impairment (Child-Pugh class A, B, or C).1

Renal impairment or end-stage renal disease: Negligible renal clearance; pharmacokinetics not affected by mild, moderate, or severe renal impairment.1

Not removed by hemodialysis.1

Stability

Storage

Parenteral

Powder for IV Infusion

2–8°C;1 do not freeze.1

Following reconstitution with sterile water for injection, store at 2–8°C for ≤1 hour;1 do not freeze.1 Following further dilution in 5% dextrose injection or 0.9% sodium chloride injection to a concentration of 0.77 mg/mL, store at 2–8°C and administer within 24 hours of preparation.1 Do not freeze.1

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Solution Compatibility

Compatible

Dextrose 5%

Sodium chloride 0.9%

Actions and Spectrum

  • Echinocandins (e.g., caspofungin, micafungin, anidulafungin) differ structurally and pharmacologically from other available antifungals.1 2 4 5 6 7 11

  • Inhibits synthesis of β-d-glucan, an essential component of fungal cell walls that is not present in mammalian cells.1 2 3 4 5 7

  • May be fungistatic or fungicidal in action.1 2 3 4 5 7 13

  • Active in vitro against Candida, including C. albicans,1 10 11 29 C. dubliniensis,11 23 C. glabrata,1 10 11 13 C. guilliermondii,1 10 C. keyfri,10 C. krusei,1 10 11 C. lusitaniae,10 C. metapsilosis,37 C. orthopsilosis,37 C. parapsilosis,1 10 37 and C. tropicalis.1 10 11 27 30 31

  • Active against some strains of fluconazole-resistant C. albicans,1 10 C. glabrata,10 29 and C. krusei.10

  • Active in vitro against Aspergillus, including A. fumigatus, A. flavus, A. niger, and A. terreus.2 4 5 6 7 11 12 27 29 30 31

  • Like other echinocandins, not active against Cryptococcus neoformans,2 4 5 11 27 29 30 31 Trichosporon,2 29 31 33 Fusarium,2 4 11 27 31 33 or zygomycetes.2 4 29 30 31 33

  • Potential for development of resistance or for cross-resistance with other echinocandins (caspofungin, micafungin) not known.1 2 6 11 12

  • Active against some strains of C. glabrata resistant to caspofungin13 and C. parapsilosis resistant to caspofungin and micafungin.36

Advice to Patients

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, and any concomitant illnesses.1

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1

  • Importance of informing patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Anidulafungin

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

For injection, for IV infusion

50 mg

Eraxis

Pfizer

100 mg

Eraxis

Pfizer

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions November 1, 2009. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

1. Pfizer Inc. Eraxis (anidulafungin) for injection prescribing information. New York, NY; 2009 Jun.

2. Denning DW. Echinocandin antifungal drugs. Lancet. 2003; 362:1142-51. [IDIS 504895] [PubMed 14550704]

3. Krause DS, Simjee AE, van Rensburg C et al. A randomized, double-blind trial of anidulafungin versus fluconazole for the treatment of esophageal candidiasis. Clin Infect Dis. 2004; 39:770-5. [PubMed 15472806]

4. Zaas AK, Alexander BD. Echinocandins: role in antifungal therapy, 2005. Expert Opin Pharmacother. 2005; 6:1657-68. [PubMed 16086652]

5. Murdoch D, Plosker GL. Anidulafungin. Drugs. 2004; 64:2249-58. [PubMed 15456342]

6. Vazquez JA. Anidulafungin: a new echinocandin with a novel profile. Clin Ther. 2005; 27:657-73. [PubMed 16117974]

7. Raasch RH. Anidulafungin: review of a new echinocandin antifungal agent. Expert Rev Anti Infect Ther. 2004; 2:499-508. [PubMed 15482216]

8. Krause DS, Reinhardt J, Vazquez JA et al. Phase 2, randomized, dose-ranging study evaluating the safety and efficacy of anidulafungin in invasive candidiasis and candidemia. Antimicrob Agents Chemother. 2004; 48:2021-4. [PubMed 15155194]

9. Dowell JA, Stogniew M, Krause D et al. Assessment of the safety and pharmacokinetics of anidulafungin when administered with cyclosporine. J Clin Pharmacol. 2005; 45:227-33. [PubMed 15647416]

10. Pfaller MA, Boyken L, Hollis RJ et al. In vitro activities of anidulafungin against more than 2,500 clinical isolates of Candida spp., including 315 isolates resistant to fluconazole. J Clin Microbiol. 2005; 43:5425-7. [PubMed 16272464]

11. Cappelletty D, Eiselstein-McKitrick K. The echinocandins. Pharmacotherapy. 2007; 27:369-88. [PubMed 17316149]

12. Vazquez JA, Sobel JD. Anidulafungin: a novel echinocandin. Clin Infect Dis. 2006; 43:215-22. [PubMed 16779750]

13. Cota J, Carden M, Graybill JR et al. In vitro pharmacodynamics of anidulafungin and caspofungin against Candida glabrata isolates, including strains with decreased caspofungin susceptibility. Antimicrob Agents Chemother. 2006; 50:3926-8. [PubMed 16940061]

14. Dowell JA, Stogniew M, Krause D et al. Lack of pharmacokinetic interaction between anidulafungin and tacrolimus. J Clin Pharmacol. 2007; 47:305-14. [PubMed 17322142]

15. Dowell JA, Stogniew M, Krause D et al. Anidulafungin does not require dosage adjustment in subjects with varying degrees of hepatic or renal impairment. J Clin Pharmacol. 2007; 47:461-70. [PubMed 17389555]

16. Philip A, Odabasi Z, Rodriguez J et al. In vitro synergy testing of anidulafungin with itraconazole, voriconazole, and amphotericin B against Aspergillus spp. and Fusarium spp. Antimicrob Agents Chemother. 2005; 49:3572-4. [PubMed 16048988]

17. Dowell JA, Schranz J, Baruch A et al. Safety and pharmacokinetics of coadministered voriconazole and anidulafungin. J Clin Pharmacol. 2005; 45:1373-82. [PubMed 16291712]

18. Benjamin DK, Driscoll T, Seibel NL et al. Safety and pharmacokinetics of intravenous anidulafungin in children with neutropenia at high risk for invasive fungal infections. Antimicrob Agents Chemother. 2006; 50:632-8. [PubMed 16436720]

19. Reboli AC, Rotstein C, Pappas PG et al. Anidulafungin versus fluconazole for invasive candidiasis. N Engl J Med. 2007; 356:2472-82. [PubMed 17568028]

21. Anon. Antifungal drugs. Treat Guidel Med Lett. 2008; 6:1-8. [PubMed 18157085]

22. Karlowsky JA, Hoban DJ, Zhanel GG et al. In vitro interactions of anidulafungin with azole antifungals, amphotericin B and 5-fluorocytosine against Candida species. Int J Antimicrob Agents. 2006; 27:174-7. [PubMed 16414247]

23. Jacobsen MD, Whyte JA, Odds FC. Candida albicans and Candida dubliniensis respond differently to echinocandin antifungal agents in vitro. Antimicrob Agents Chemother. 2007; 51:1882-4. [PubMed 17307974]

24. Pappas PG, Kauffman CA, Andes D et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009; 48:503-35. [PubMed 19191635]

25. Mofenson LM, Brady MT, Danner SP et al. Guidelines for the Prevention and Treatment of Opportunistic Infections among HIV-exposed and HIV-infected children: recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics. MMWR Recomm Rep. 2009; 58:1-166. [PubMed 19730409]

26. Kaplan JE, Benson C, Holmes KH et al. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep. 2009; 58:1-207; quiz CE1-4.

27. Estes KE, Penzak SR, Calis KA et al. Pharmacology and antifungal properties of anidulafungin, a new echinocandin. Pharmacotherapy. 2009; 29:17-30. [PubMed 19113794]

28. Damle BD, Dowell JA, Walsky RL et al. In vitro and in vivo studies to characterize the clearance mechanism and potential cytochrome P450 interactions of anidulafungin. Antimicrob Agents Chemother. 2009; 53:1149-56. [PubMed 19029327]

29. Morris MI, Villmann M. Echinocandins in the management of invasive fungal infections, part 1. Am J Health Syst Pharm. 2006; 63:1693-703. [PubMed 16960253]

30. Kauffman CA, Carver PL. Update on echinocandin antifungals. Semin Respir Crit Care Med. 2008; 29:211-9. [PubMed 18366002]

31. Kim R, Khachikian D, Reboli AC. A comparative evaluation of properties and clinical efficacy of the echinocandins. Expert Opin Pharmacother. 2007; 8:1479-92. [PubMed 17661730]

32. Juang P. Update on new antifungal therapy. AACN Adv Crit Care. 2007 Jul-Sep; 18:253-60; quiz 261-2.

33. de la Torre P, Meyer DK, Reboli AC. Anidulafungin: a novel echinocandin for candida infections. Future Microbiol. 2008; 3:593-601. [PubMed 19072176]

34. Vazquez JA, Schranz JA, Clark K et al. A phase 2, open-label study of the safety and efficacy of intravenous anidulafungin as a treatment for azole-refractory mucosal candidiasis. J Acquir Immune Defic Syndr. 2008; 48:304-9. [PubMed 18545153]

35. Eschenauer G, Depestel DD, Carver PL. Comparison of echinocandin antifungals. Ther Clin Risk Manag. 2007; 3:71-97. [PubMed 18360617]

36. Moudgal V, Little T, Boikov D et al. Multiechinocandin- and multiazole-resistant Candida parapsilosis isolates serially obtained during therapy for prosthetic valve endocarditis. Antimicrob Agents Chemother. 2005; 49:767-9. [PubMed 15673762]

37. Lockhart SR, Messer SA, Pfaller MA et al. Geographic distribution and antifungal susceptibility of the newly described species Candida orthopsilosis and Candida metapsilosis in comparison to the closely related species Candida parapsilosis. J Clin Microbiol. 2008; 46:2659-64. [PubMed 18562582]

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