Cost-utility analysis of caspofungin and fluconazole for primary treatment of invasive candidiasis and candidemia in Ethiopia

Availability and cost of antifungal therapy in Vietnam: A 5-year retrospective study

Access to antifungal agents for the treatment of invasive fungal infections (IFIs) varies significantly between countries. Limited access or high cost may contribute to the burden of IFIs. We aimed to investigate the availability and cost of antifungal treatment for IFIs in Vietnam. Procurement data from 2018 to 2022 was collected from the Drug Administration of Vietnam website. We calculated the cost per defined daily dose (DDD) and identified the manufacturing countries. We explored the pharmacotherapy cost of the four major IFIs if first-line agents were used in accordance with the Vietnam 2021 antifungal prescribing guideline. We also estimated the treatment expenditure in 2020 based on the estimated disease burden previously published and suggested cost-saving measures. At least 57.6 million USD was spent on 15.5 million DDD of antifungals in 5 years. Seven systemic antifungal agents were available in Vietnam. Caspofungin and micafungin were the least used but most expensive, whereas fluconazole and itraconazole were the most consumed but cheapest antifungals. Vietnam manufactured 70% of azole antifungals and relied on imports for the remaining antifungals consumed. We estimated the first-line pharmacological treatment for the estimated cases of four IFIs in 2020 to cost at least 209.1 million USD, which exceeded the actual spend in 2020. We discovered that antifungal agents for IFIs impose a substantial economic burden on Vietnam's healthcare system. We highlight the need for cost-effectiveness studies of expensive first-line medications. Efforts to mitigate this economic burden should include antifungal stewardship, prevention of IFIs, and sourcing from cost-effective manufacturers.

Invasive candidiasis

Invasive candidiasis is an important fungal disease caused by Candida albicans and, increasingly, non-albicans Candida pathogens. Invasive Candida infections originate most frequently from endogenous human reservoirs and are triggered by impaired host defences. Signs and symptoms of invasive candidiasis are non-specific; candidaemia is the most diagnosed manifestation, with disseminated candidiasis affecting single or multiple organs. Diagnosis poses many challenges, and conventional culture techniques are frequently supplemented by non-culture-based assays. The attributable mortality from candidaemia and disseminated infections is ~30%. Fluconazole resistance is a concern for Nakaseomyces glabratus, Candida parapsilosis, and Candida auris and less so in Candida tropicalis infection; acquired echinocandin resistance remains uncommon. The epidemiology of invasive candidiasis varies in different geographical areas and within various patient populations. Risk factors include intensive care unit stay, central venous catheter use, broad-spectrum antibiotics use, abdominal surgery and immune suppression. Early antifungal treatment and central venous catheter removal form the cornerstones to decrease mortality. The landscape of novel therapeutics is growing; however, the application of new drugs requires careful selection of eligible patients as the spectrum of activity is limited to a few fungal species. Unanswered questions and knowledge gaps define future research priorities and a personalized approach to diagnosis and treatment of invasive candidiasis is of paramount importance.

Fungal Infections, Treatment and Antifungal Resistance: The Sub-Saharan African Context

Fungal pathogens cause a wide range of infections in humans, from superficial to disfiguring, allergic syndromes, and life-threatening invasive infections, affecting over a billion individuals globally. With an estimated 1.5 million deaths annually attributable to them, fungal pathogens are a major cause of mortality in humans, especially people with underlying immunosuppression. The continuous increase in the population of individuals at risk of fungal infections in sub-Saharan Africa, such as HIV patients, tuberculosis patients, intensive care patients, patients with haematological malignancies, transplant (haematopoietic stem cell and organ) recipients and the growing global threat of multidrug-resistant fungal strains, raise the need for an appreciation of the region's perspective on antifungal usage and resistance. In addition, the unavailability of recently introduced novel antifungal drugs in sub-Saharan Africa further calls for regular evaluation of resistance to antifungal agents in these settings. This is critical for ensuring appropriate and optimal use of the limited available arsenal to minimise antifungal resistance. This review, therefore, elaborates on the multifaceted nature of fungal resistance to the available antifungal drugs on the market and further provides insights into the prevalence of fungal infections and the use of antifungal agents in sub-Saharan Africa.

Evaluation of Fluconazole versus Echinocandins for Treatment of Candidemia Caused by Susceptible Common Candida Species: A Propensity Score Matching Analysis

This study aimed to evaluate the effectiveness of fluconazole and echinocandins in the treatment of candidemia caused by both fluconazole- and echinocandin-susceptible common Candida species. A retrospective study which enrolled adult candidemia patients ≥19 years diagnosed at a tertiary care hospital in the Republic of Korea from 2013 to 2018 was conducted. Common Candida species were defined as C. albicans, C. tropicalis, and C. parapsilosis. Cases of candidemia were excluded based on the following exclusion criteria: (1) candidemia showed resistance to either fluconazole or echinocandins, or (2) candidemia was caused by other Candida species than common Candida species. In order to compare the mortality rates between patients who receive fluconazole or echinocandins, the propensity scores on variables of baseline characteristics using the multivariate logistic regression analysis were employed to balance the antifungal treatment groups, and a Kaplan-Meier survival analysis was performed. Fluconazole and echinocandins were used in 40 patients and in 87 patients, respectively. The propensity score matching included 40 patients in each treatment group. After matching, the rates of 60-day mortality after candidemia were 30% in the fluconazole group and 42.5% in the echinocandins group, and a Kaplan-Meier survival analysis showed no significant difference between antifungal treatment groups, p = 0.187. A multivariable analysis demonstrated that septic shock was significantly associated with the 60-day mortality, whereas fluconazole antifungal treatment was not associated with an excess 60-day mortality. In conclusion, our study results suggest that fluconazole use in the treatment of candidemia caused by susceptible common Candida species may be not associated with increased 60-day mortality compared to echinocandins.