Antifungal agents are available in systemic and topical formulations,
and some are available in both forms. Topical antifungal agents,
because they are poorly absorbed, are less likely to cause toxicity
and should, as a rule, be the first choice for treating skin and
mucous membrane infections. However, tinea capitis and onychomycosis (fungal
infection of the nails) are best treated systemically (see Chapter 367). Infections that are severe,
are disseminated, or involve the bloodstream should also be treated
with systemic therapy. During the past 10 years, many potent new
systemic agents have become available. Organism- and disease-specific
antifungal therapies are summarized in Table 247-1.
Table 247-1. Antifungal
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Table 247-1. Antifungal
|Organism or Condition||Disease||Therapy|
|Aspergillus(spp)1||Invasive, central nervous system, or sinus infection||Voriconazole 14 mg/kg/day IV, divided every
12 hours or 400 mg/day PO, divided every 12 hours. Alternate
therapies include lipid formulations of amphotericin B 5 mg/kg/day,
caspofungin 70 mg/m2 loading dose followed
by 50 mg/m2/day, micafungin 3
mg/kg/day, maximum dose of 150 mg, posaconazole
800 mg/day divided every 6 or 12 hours, or itraconazole
10 mg/kg/day, divided every 12 hours. Therapy
should continue for a minimum of 6–12 weeks based on clinical
course and underlying host status. CNS infections may require prolonged
duration of therapy. Surgical removal of involved tissue is recommended
by some experts. Note that A terreus may be resistant to
|Skin||Surgical débridement or wide margin surgical resection.
Antifungal therapy same as above. Following adequate débridement
and recovery of immunosuppression, shorter duration of therapy may
|Blastomyces dermatitidis2||Pulmonary and disseminated||Amphotericin B 0.5–1.0 mg/kg/day
for moderate to severe infections. Itraconazole 4–10 mg/kg/day, divided
every 12 hours for mild to moderate infections. Duration of therapy
is 6 months for itraconazole and 1.5–2 grams total dose
amphotericin B (recommended adult dosage). Voriconazole and posaconazole
may also be active agents, but there is limited clinical experience.|
|Candida (spp)3,4||Oropharyngeal candidiasis (thrush)||Infants: nystatin oral suspension 2 mL QID for at least 7
|Children: nystatin oral suspension 5 mL QID, swish and swallow,
or clotrimazole troche, 10 mg, 5 times daily × 7
|Immunocompromised or failed topical therapy: fluconazole
IV or PO, 6 mg/kg, loading dose followed by 3 mg/kg/day
for total of 14 days.|
|Cutaneous||Nystatin or clotrimazole or miconazole cream, lotion, or
powder applied twice a day for at least 7 days.|
|Vaginitis||Topical azole or nystatin for 1–7 days or single-dose
fluconazole 150 mg (adult dosage). Duration of therapy and selection
of topical or systemic therapy based on clinical features.|
|Esophagitis||Fluconazole, IV or PO, 6 mg/kg loading dose followed
by 3 mg/kg/day for total of 14 days. Alternative therapy,
especially in situations where fluconazole-resistant Candida suspected
or prior failure: voriconazole 14 mg/kg/day IV,
divided every 12 hours or 400 mg/day PO, divided every
12 hours, posaconazole ...|
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