Empirical antifungal
therapy is recommended in high-risk patients who have persistent
febrile neutropenia (FN) despite broad-spectrum
antibiotic therapy. Based on high-quality evidence, most guidelines recommend
caspofungin. The aim of this study was to clarify whether
echinocandins, including
micafungin, are associated with improved clinical outcomes in patients with persistent FN. We conducted a meta-analysis of randomized controlled trials (RCTs) of empirical
therapy with
echinocandins and non-
echinocandins for FN in patients with
hematological disease. The primary outcome was all-cause mortality within 7 days after completion of
therapy. Secondary outcomes included treatment success, and discontinuation of
therapy because of adverse events. For subgroup analysis, we compared RCTs of
echinocandins with
liposomal amphotericin B. Six RCTs (four that evaluated
caspofungin and two that evaluated
micafungin) were included in the meta-analysis. Mortality and adverse events in
echinocandin-treated patients were significantly lower than in those treated with non-
echinocandins [risk ratio (RR) 0.70, 95% confidence interval (CI) 0.49-0.99; RR 0.48, 95% CI 0.33-0.71, respectively]. There was no significant difference in treatment success (RR 1.09, 95% CI 0.87-1.36). Mortality and adverse events in
echinocandin-treated patients were significantly lower than in those treated with
liposomal amphotericin B (RR 0.68, 95% CI 0.46-0.99; RR 0.53, 95% CI 0.37-0.74, respectively). In conclusion, patients with persistent FN treated with
echinocandins had decreased risk of death and adverse events. Both
caspofungin and
micafungin may be recommended as first-line empirical antifungal
therapy in these patients. However, the small number of enrolled patients and the lack of RCTs involving pediatric patients should be considered when using
micafungin.