Micafungin Dosing in Severe Sepsis with Possible Abdominal Source

First-Line Treatment Recommendations

The American College of Physicians recommends echinocandins, including micafungin, as the preferred first-line agents for suspected or confirmed invasive candidiasis in critically ill patients 1, 2
Standard dosing for micafungin in severe sepsis with possible abdominal source is 100 mg IV daily, as recommended by the Infectious Diseases Society of America 1, 2
All echinocandins (micafungin, caspofungin, anidulafungin) are considered equally effective for candidemia and invasive candidiasis, according to the Clinical Infectious Diseases guidelines 1

Surgical intervention is strongly recommended in addition to antifungal therapy for intra-abdominal candidiasis, as stated by the Clinical Infectious Diseases guidelines 3
For suspected or confirmed fluconazole-resistant Candida species, the standard micafungin dose of 100 mg daily is recommended, according to the Clinical Infectious Diseases guidelines 3, 4

Treatment should continue for at least 2 weeks after documented clearance of Candida from the bloodstream and resolution of symptoms attributable to candidemia, as recommended by the Infectious Diseases Society of America 1, 2

Monitor for clinical response and clearance of Candida from the bloodstream, as recommended by the Infectious Diseases Society of America 2
Perform dilated funduscopic examinations to rule out endophthalmitis in patients with candidemia, according to the Infectious Diseases Society of America guidelines 2
For persistent candidemia, consider imaging of the genitourinary tract, liver, and spleen, as recommended by the Infectious Diseases Society of America 2

Delay in initiating appropriate antifungal therapy is associated with increased mortality, with mortality approaching 100% in patients with septic shock due to Candida without adequate source control or antifungal therapy within 24 hours, as stated by the Infectious Diseases Society of America 2
Failing to continue therapy for a sufficient duration (at least 2 weeks after blood culture clearance) is a common pitfall, according to the Infectious Diseases Society of America guidelines 1
Premature switching to fluconazole before confirming species identification and susceptibility, especially in critically ill patients, should be avoided, as recommended by the Infectious Diseases Society of America 1

The Infectious Diseases Society of America recommends a higher dose of 150-200 mg daily for moderate to severe esophageal candidiasis, especially in cases that are fluconazole-refractory 5
The Infectious Diseases Society of America suggests that a higher dose of 200 mg daily may be more effective when treating patients with suspected or confirmed fluconazole-resistant Candida infections 6

The Infectious Diseases Society of America recommends continuing treatment for at least 2 weeks after documented clearance of Candida from the bloodstream and resolution of symptoms, and for complicated infections such as deep tissue infections, longer courses may be necessary 6
The Infectious Diseases Society of America advises that premature discontinuation can lead to relapse and should be avoided 6

The 2016 IDSA guidelines provide strong recommendations for echinocandin use in invasive candidiasis, and support the use of higher doses (200 mg) in specific scenarios, though with somewhat lower quality evidence 6