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Pharmacology of echinocandins

Russell E Lewis, PharmD, FCCP
Section Editor
Carol A Kauffman, MD
Deputy Editor
Anna R Thorner, MD


The development of echinocandins, the first class of antifungals to target the fungal cell wall, was a milestone achievement in antifungal chemotherapy. Echinocandins were discovered as fermentation metabolites with antifungal activity during screening programs for new antibiotics [1]. The candidate molecules were subsequently modified to improve solubility, antifungal spectrum of activity, and pharmacokinetic characteristics [2]. Three semi-synthetic echinocandin derivatives have been developed for clinical use: caspofungin, micafungin, and anidulafungin.

All three echinocandins are structurally similar cyclic hexapeptide antibiotics with modified N-linked acyl lipid side chains (figure 1), which play a role in anchoring the hexapeptide nucleus to the fungal cell membrane where the drug interacts with the target enzyme complex involved in cell wall synthesis [3]. Like other large lipopeptide antibiotics, these drugs have limited oral bioavailability and must be administered by intravenous infusion. Experience with this antifungal class suggests that it is among the best tolerated and safest class of antifungals available.

The pharmacology of echinocandin antifungals will be reviewed here. Indications for the clinical use of echinocandins, antifungal susceptibility testing, and the pharmacology of other systemic antifungal agents, such as amphotericin B, the azoles, and flucytosine, are discussed separately. (See "Treatment of candidemia and invasive candidiasis in adults" and "Treatment and prevention of invasive aspergillosis" and "Antifungal susceptibility testing" and "Pharmacology of amphotericin B" and "Pharmacology of azoles" and "Pharmacology of flucytosine (5-FC)".)


Echinocandins are widely used for the treatment of invasive candidiasis, especially in critically ill and neutropenic patients [4]. They are also used for empiric antifungal therapy in patients with neutropenic fever. They are sometimes used in combination with voriconazole for the initial treatment of invasive aspergillosis or as part of a combination antifungal regimen with voriconazole or a lipid formulation of amphotericin B for salvage therapy of invasive aspergillosis. (See "Treatment and prevention of invasive aspergillosis".)

The major advantages of echinocandins relative to other antifungal agents are their fungicidal activity against Candida spp, including fluconazole-resistant C. glabrata and C. krusei, combined with their relatively low potential for renal or hepatic toxicity or serious drug-drug interactions. Specific recommendations regarding the use of these agents are presented separately. (See "Treatment of candidemia and invasive candidiasis in adults" and "Treatment and prevention of invasive aspergillosis" and "Treatment of neutropenic fever syndromes in adults with hematologic malignancies and hematopoietic cell transplant recipients (high-risk patients)", section on 'Addition of an antifungal agent'.)

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Literature review current through: Dec 2017. | This topic last updated: Sep 29, 2017.
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