Clinical trial NCT00723073: Caspofungin or Micafungin as Empiric Antifungal Therapy for Persistent Fever and Neutropenia
Official title: Evaluation of Caspofungin or Micafungin as Empiric Antifungal Therapy in Adult Patients With Persistent Febrile Neutropenia: A Retrospective, Observational, Sequential Cohort Analysis
Study type: OBSERVATIONAL
Overall status: COMPLETED
Conditions: Febrile Neutropenia
Keywords: micafungin, caspofungin, febrile neutropenia
Lead sponsor: Brigham and Women's Hospital
Sponsor class: OTHER
Collaborators: name: Astellas Pharma US, Inc.
First posted: 2008-07-28
Enrollment: 323
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Observational model: COHORT
Time perspective: RETROSPECTIVE
Sampling method: NON_PROBABILITY_SAMPLE
Study population: Cancer patients who are persistently febrile and neutropenic after receiving broad spectrum antibiotics and receive empiric antifungal therapy with either caspofungin or micafungin

Brief summary: Invasive fungal infections are an important cause of morbidity and mortality in patients with neutropenia who are receiving chemotherapy for cancer. Early diagnosis of these infections is difficult and fever may be the only sign. A delay in treatment while a diagnosis is pursued may lead to increased morbidity and mortality. There are now several echinocandins available with similar in vitro spectrum of activity. Caspofungin is the only echinocandin Food and Drug Administration (FDA) approved for empiric antifungal therapy in febrile neutropenia. Although all echinocandin antifungal agents have similar spectrum of activity, there are limited data on the use of micafungin in patients with persistent fever and neutropenia (FN). In November 2006 the Pharmacy and Therapeutics Committee at Brigham \& Women's Hospital / Dana Farber Cancer Institute (BWH/DFCI) switched from caspofungin to micafungin as our formulary echinocandin. Given the limited clinical data on the use of micafungin as empiric antifungal therapy in patients with FN, we sought to evaluate the safety and effectiveness of micafungin, compared with caspofungin, for this indication using a sequential cohort analysis of patients treated before and after the formulary change at Brigham and Women's Hospital.

Detailed description: Objectives

This retrospective cohort analysis of converting from caspofungin to micafungin as empiric antifungal therapy for cancer patients who are persistently febrile and neutropenic after receiving broad spectrum antibiotics at Brigham \& Women's Hospital / Dana Farber Cancer Institute (BWH/DFCI) is designed to evaluate the following objectives:

* Safety of micafungin in this patient population
* Effective dose of 100 mg daily of micafungin compared to 70mg x1, then 50 mg daily of caspofungin
* Economic impact of converting or formulary echinocandin from micafungin to caspofungin

Study Design

* Retrospective cohort analysis - limited to medical records
* Data to be collected include the following:

  * Demographic information: including: gender, age, race
  * Past medical history and admitting diagnoses
  * Laboratory results: Liver function tests (LFTs), Including alanine aminotransferase (ALT), aspartate aminotransferase (AST), Total bilirubin, as well as serum fungal assays: Serum Galactomannan assay, 1.3-BD Glucan assay
  * Concomitant medications and duration of therapy for all systemic: antibiotics and antifungals
  * All invasive breakthrough fungal infection details, including speciation and outcomes during echinocandin therapy
  * Dosing, duration, and adverse events associated with echinocandin therapy

Eligibility criteria: Inclusion Criteria:

* All patients admitted to BWH/DFCI who received at least 2 doses of caspofungin with an Absolute Neutrophil Count (ANC) \< 500, for persistent febrile neutropenia from 11/1/2005 - 10/31/2006, as there first antifungal agent.
* All patients admitted to BWH/DFCI who received at least 2 doses of micafungin with an Absolute Neutrophil Count (ANC) \< 500 for persistent febrile neutropenia from 11/1/2006 - 10/31/2007 as there first antifungal agent

Exclusion Criteria:

* Patients receiving an echinocandin antifungal agent (micafungin or caspofungin) for an indication other then empiric therapy in febrile neutropenia
* Patients receiving therapy for an active or on-going invasive fungal infection
* Patients who received both caspofungin and micafungin during the same admission
* Patients with an ANC \> 500 at when either micafungin or caspofungin was started
* Patients who received another antifungal agent for persistent febrile neutropenia, e.g., voriconazole, amphotericin B liposome, posaconazole, etc... Before they received an echinocandin (caspofungin or micafungin) will be excluded

Primary outcomes:
measure: Composite Primary Endpoint: Number of Participants With an Overall Favorable Response to Echinocandin Therapy for Empiric Antifungal Therapy for Persistent Febrile Neutropenia (FN)
timeFrame: 11/1/2005 - 10/31/2007
measure: Successful Treatment of Any Baseline Invasive Fungal Disease (IFD)
timeFrame: 11/1/2005 - 10/31/2007
measure: Mortality at Hospital Discharge
timeFrame: 11/1/2005 - 10/31/2007
measure: Absence of Any Breakthrough Invasive Fungal Disease (IFD)
timeFrame: 11/1/2005 - 10/31/2007
measure: Lack of an Adverse Drug Event (ADE) Attributable to Echinocandin (EC) Therapy That Led to Discontinuation of Therapy
timeFrame: 11/1/2005 - 10/31/2007
Secondary outcomes:
measure: Duration of Echinocadin Therapy for Persistent Febrile Neutropenia (FN)
timeFrame: 11/1/2005 - 10/31/2007
measure: Liver Function Tests (LFTs) Elevated During or After Echinocandin Therapy
timeFrame: 11/1/2005 - 10/31/2007
measure: Specific Type of Adverse Event That Resulted in Echinocandin (EC) Therapy Discontinuation
timeFrame: 11/1/2005 - 10/31/2007
measure: Duration of Hospitization
timeFrame: 11/1/2005 - 10/31/2007
measure: Duration of Neutropenia
timeFrame: 11/1/2005 - 10/31/2007
Other outcomes:
Locations:
city: Boston
country: United States
facility: Brigham and Women's Hospital
state: Massachusetts
Study officials:
affiliation: Brigham and Women's Hospital
name: David W Kubiak, PharmD
role: PRINCIPAL_INVESTIGATOR
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