Micafungin in Hematology: Current Evidence and Clinical Positioning

This narrative review summarizes current evidence on the role of micafungin in patients with hematologic malignancies and hematopoietic stem cell transplantation (HSCT), a population at high risk for invasive fungal infections (IFIs). Micafungin, an echinocandin with activity against most Candida spp. and Aspergillus spp., is characterized by a favorable safety profile, predictable pharmacokinetics, and minimal drug-drug interactions, making it particularly attractive in patients receiving complex targeted therapies. Micafungin has a well-established role in the prevention of IFIs in selected patients with hematologic malignancies, particularly during induction chemotherapy for acute myeloid leukemia/myelodysplastic syndromes and during the pre-engraftment period after allogeneic HSCT when the local risk of invasive mould disease is low. Its use in emerging populations such as cellular-therapy and bispecific-antibody recipients should be individualized because micafungin-specific evidence remains limited. Micafungin is also an established treatment option for invasive candidiasis, although species identification, susceptibility testing, appropriate step-down therapy, and consideration of site-specific limitations are essential. Evidence supporting empirical treatment of febrile neutropenia is supportive but comparatively limited. Its role in invasive aspergillosis remains limited, mainly as salvage or combination therapy, and its lack of activity against certain moulds and rare fungi should be considered. The emergence of Candidozyma auris (C. auris) and echinocandin-resistant Candida spp. further underscores the importance of species identification, susceptibility testing, and clinical surveillance. Extended-interval and intermittent micafungin dosing may offer practical advantages and pharmacokinetic feasibility, but clinical noninferiority to daily administration has not been established and such regimens remain off-label and investigational. Overall, its optimal use requires careful patient selection and awareness of its spectrum limitations, supporting a tailored approach to antifungal management in hematologic patients.