Echinocandins - first line in invasive candidiasis how strong is this strong evidence.docVIP

Gon?alves-Pereira and Póvoa Critical Care 2011,15:461 /content/15/6/461 LET TER Echinocandins – ? rst line in invasive candidiasis: how strong is this ‘strong’ evidence? Jo?o Gon?alves-Pereira* and Pedro Póvoa 1,2 1,2 See related research by Kett et al., /content/15/5/R253 In the previous issue of Critical Care, Kett and colleagues anidulafungin received, on average, 3 more days of intra- [1] published a post hoc analysis of a randomized venous therapy than the ? uconazol group. Besides, more controlled trial comparing the e? cacy of anidulafungin patients in the anidulafungin arm had their central versus ? uconazole in non-neutropenic critically ill venous catheter remove ese facts markedly biased patients with invasive Candida infections (89% had the results and could explain the observed di? erences [4]. candidemia). But the authors’ claim that their data support the superiority of anidula fungin may be misleading and raises several concerns. First, the primary ird, this was a non-inferiority st erefore, from a statis tical point of view, any conclusions regarding superiority must be interpreted with extreme caution [5]. endpoint of the study was clinical and microbiological Finally, at the time of the study design [3], the use of success at the end of intravenous therapy. However, amphotericin B, and not ? uconazole, was recommended surrogate endpoints must be predictive of the clinically in unstable patients with invasive Candida infections. relevant endpoint that is mort at was not the erefore, the choice of ? uconazole as a comparator case, and no di? erence in 28-day mortality was noted limits the study conclusions even further. We believe (20.2% versus 24.3%; P = 0.57). Second, in the