OBJECTIVES: The prevalence of systemic Candida infection (SCI) caused by non-albicans species, which display greater resistance to azole antifungal agents, is increasing. Treatment with broad-spectrum antifungal agents, such as echinocandins, with subsequent switch to fluconazole if isolates are shown to be sensitive (‘de-escalation’) is recommended by treatment guidelines. We developed a model to assess the budget impact of the de-escalation strategy in France and Germany. METHODS: The budget impact of initial micafungin treatment in a de-escalation strategy versus fluconazole in an escalation strategy was modelled using decision analysis based on data from relevant studies and a cost-effectiveness analysis. Duration of appropriate treatment was 14 days, meaning that treatment outcome was assessed after 14 days, or 17 days if fluconazole had to be switched once fluconazole sensitivity was known (after 3 days of therapy). Clinical success was defined as resolution or reduction of all signs, symptoms and radiographic abnormalities associated with SCI at treatment end. RESULTS: In France and Germany, the incidence of SCI was estimated at 28 and 38/100,000 population/year, respectively. In both countries, the most common isolates were C. albicans, C. parapsilosis and C. glabrataCONCLUSIONS: Across all patient groups, de-escalation from micafungin improved clinical outcome and survival. This was particularly marked in patients with fluconazole-resistant SCI, in whom de-escalation from micafungin was cost-saving. Increased costs with de-escalation in the overall population are limited and offset by improvement in survival using this strategy.