CONSIDERATIONS FOR OUTPATIENT ECHINOCANDIN THERAPY

What happens as patients transition from their initial therapy for invasive candidiasis? Most patients change or “step down” from IV antifungal therapy to oral therapy for invasive candidiasis, often to an azole. However, some patients require longer-term treatment with echinocandins. This is typically required for people with

• Infected prosthetic materials (for example, cardiac devices, vascular grafts). These materials can become infected with Candida, and they are not easily removed.
• Infection of the bone or joints
• Patients with disseminated candidiasis who are on long-term therapies that suppress their immune systems (e.g., patients with cancer who have immune systems suppressed by anticancer drug)
• Patients with chronic Candida infection of their mucous membranes who have immunodeficiency
• People unable to receive oral antifungal therapies because they have a type of Candida that is resistant to those drugs or because they can’t tolerate the oral therapy
• People who have trouble clearing the infection (for example, have a challenging resistant fungus but they are otherwise doing ok medically)

Learn about the invasive candidiasis journeys of our patient advocates, Ryan and Stephanie.

Ryan and Emmy: Our story with chronic Candida auris

Stephanie’s story of chronic invasive candidiasis

Making the Decision That’s Best for You

If you require long-term management of invasive candidiasis, there are some things to consider as you and your provider assess the best route forward. You may have a few options including:

• At home infusion through a vascular access device. This could include daily vs weekly echinocandin therapy.
• Administration in an infusion center. This could be daily echinocandin or weekly echinocandin. Typically, an IV can be started as needed.
• Transition to oral therapy. If your condition improves, you may be able to transition to oral therapy after a period of IV echinocandin therapy.

How do you and your team decide the best route for you? Here are some questions to consider:

• Does your provider have experience with the range of options available (once-daily echinocandins vs once-weekly rezafungin)?
• What will your insurance cover? Your provider can find resources to help support patient access to the drug rezafungin at https://rezzayo.com/patient-support-resources
• Do you have ready access to an infusion center?
• If you were to receive home-based therapy, do you have support to deliver an IV (visiting nursing, etc)?
• What are your limitations in terms of travel and time?

For more discussion of these points, see the video on Shared Decision-Making below.

Decision Making for Outpatient Echinocandins: Why and How?

Knowing What to Expect from At-Home Therapy

Often, if you are sent home on an echinocandin, you will have received at least one dose in the hospital setting. Your healthcare team will assess whether you show any signs of an allergic reaction while you are in the hospital. However, you and your caregiver should know what to look for as well. Things to look out for include:

• Difficulty breathing or wheezing
• Swelling of the lips, face, tongue, or throat
• Hives, itching, or a severe skin rash (red, swollen, blistered, or peeling skin)
• Tightness in the chest or throat
• Unusual hoarseness
• Feeling faint, dizzy, or lightheaded
• Rapid or irregular heartbeat

Sometimes, less serious reactions occur that are caused by the echinocandin infusion itself (and histamine release). This can happen when the infusion is too rapid. This can include flushing, itching, nausea, fever, chills, chest tightness, and lowered blood pressure. The infusion reactions can sometimes be managed by slowing or pausing the drip and providing antihistamine drugs. You should work with your infusion provider and healthcare provider if these things happen.

To learn more about what to expect and look for with the first echinocandin doses, see the video below:

Preparation of the IV and the First Doses

Beyond addressing the side effects of the therapy, you should also be prepared to take care of your vascular access device. Most patients receiving an echinocandin in the outpatient setting will have a PICC line inserted. PICC stands for peripherally inserted central catheter (PICC). This is typically inserted in the hospital and can stay in place for months. As shown in the image, the PICC line is typically inserted into a large vein in the upper arm and then advanced to a larger vein right above the heart. This allows the drugs to be given with less irritation. With a PICC line, the patient does not have to have an IV placed every time.

Things to look out for with a PICC Line include:

• The PICC line getting pulled out. If the PICC line comes out, DO NOT try to push it back in. Instead, use gauze or something clean to apply pressure for 10-15 minutes to stop the bleeding, Once the bleeding stops, cover the area. If part of the catheter fell out, save it and bring it to your healthcare provider. Call your doctor or infusion nurse immediately (this is a medical emergency). Go directly to the emergency room.
• Infection. Signs and symptoms of infection or blood clot include: redness, pain, swelling in the PICC line arm, difficulty flushing the line, fever, chills, rash, shortness of breath or chest pain.

If you experience any of these symptoms, contact the infusion center/your healthcare provider.

Other important considerations for managing your PICC line include:

• Hand Hygiene: Wash hands with soap and water for 20+ seconds or use alcohol-based sanitizer (60%+ alcohol) before touching the line.
• Dressing Care: Keep the dressing clean, dry, and intact; change it if wet, dirty, or lifted. Use a plastic cover when showering, or sponge bathe if instructed.
• Site Checks: Look daily for redness, swelling, warmth, discharge, or pain.
• Flushing: Flush the line as directed (often daily) with sterile saline or heparin to prevent clogs; don’t use force.
• Activity: Avoid lifting over 10 lbs or strenuous activity with that arm; light arm exercises are usually okay.
• Protection: Keep pets away; wear a protective sleeve; don’t use sharp objects nearby.
• Keeping it dry: Simple measures work well (trash bag and duct tape), but there are other resources available on Amazon.

Alternatively, some patients have a more permanent vascular access device, often called a Port-a-Cath. These patients have to watch out for similar issues but because their vascular access device is in the chest region, it’s at lower risk of being pulled out.

To learn more about administration of echinocandins at home, see the video below:

Administration at Home

Knowing What to Expect When Receiving an Echinocandin at an Infusion Center

These are some of the things to consider if you are receiving an echinocandin at an infusion center:

• It’s helpful to bring a support person and entertainment.
• Dress comfortably, typically with a button-down shirt.
• You may have to have bloodwork.
• If you don’t need vascular access established long term, the nurse will set up the IV each time. After the check-in and set up time, the infusion typically lasts 1 hour.

You still should be aware of the signs and symptoms of an allergic or infection reaction and alert the staff if you develop any symptoms.

To learn more about echinocandin administration at the infusion center, see the video below:

Administration at the Infusion Center