The Expert Committee noted that there is good evidence to support the use of echinocandin antifungals in the empiric treatment of suspected or proven invasive Candida infections in critically ill patients (especially where the probability of azole resistance is high). Therefore, the Committee recommended echinocandins be added to the EML and EMLc for this indication. The Committee noted that fluconazole (which can be taken orally and is substantially cheaper than echinocandins) is still effective and has a good safety profile for prophylaxis and treatment of invasive and oesophageal Candida infections; therefore it did not recommend listing echinocandins for these indications. The Committee acknowledged the potential role for echinocandins in the second-line treatment of invasive Aspergillus infections but did not recommend listing echinocandins for this indication given the availability of established alternatives.
The Committee recommended listing micafungin as the representative medicine, noting that: the patent has recently expired; micafungin is approved for use in neonates and paediatric patients; it is widely available globally; and it has the simplest dosing scheme (caspofungin and anidulafungin require loading doses). The Committee recommended anidulafungin and caspofungin be included with the listing as therapeutic alternatives, and that all three echinocandins be considered equivalent for procurement purposes.
The Committee noted that echinocandins are expensive medicines and considerably more expensive than amphotericin B and fluconazole in most settings. Furthermore, antifungal resistance is becoming an increasing problem in many settings (mostly to azoles but also described for echinocandins). The Committee therefore stressed the importance of antimicrobial stewardship activities to support the appropriate use of echinocandins.