“De-escalation” strategy using micafungin for the treatment of systemic Candida infections: budget impact in France and Germany

Background The incidence of azole-resistant Candida infections is increasing. Consequently, guidelines for treating systemic Candida infection (SCI) recommend a "de-escalation" strategy: initial broad-spectrum antifungal agents (e.g., echinocandins), followed by switching to fluconazole if isolates are fluconazole sensitive, rather than "escalation" with initial fluconazole treatment and then switching to echinocandins if isolates are fluconazole resistant. However, fluconazole may continue to be used as first-line treatment in view of its low acquisition costs. The aim of this study was, therefore, to evaluate the budget impact of the de-escalation strategy using micafungin compared with the escalation strategy in France and Germany. Methods A budget impact model was used to compare de-escalation to escalation strategies. As well as survival, clinical success (resolution/reduction of symptoms and radiographic abnormalities associated with fungal infection), was considered, as was mycological success (eradication of Candida from the bloodstream). Health economic outcomes included cost per health state according to clinical success and mycological success, and budget impact. A 42-day time horizon was used. Results For all patients with SCI, the budget impact of using de-escalation rather than escalation was greater, but improved rates of survival, clinical success and mycological success were apparent with de-escalation. In patients with fluconazole-resistant isolates, clinical success rates and survival were improved by ~72% with de-escalation versus escalation, producing cost savings of €6,374 and €356 per patient in France and Germany, respectively; improvements of ~72% in mycological success rates with de-escalation versus escalation did not translate into cost savings. Conclusion Modeling provides evidence that when treating SCI in individuals at risk of azole-resistant infections, de-escalation from micafungin has potential cost savings associated with improved clinical success rates.