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
amphotericin B. |
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
be acceptable. |
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
days. |
Children: nystatin oral suspension 5 mL QID, swish and swallow,
or clotrimazole troche, 10 mg, 5 times daily × 7
days. |
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 800 mg/day divided every 6 or 12
hours, caspofungin 70 mg/m2 loading dose
followed by 50 mg/m2/day, micafungin
3 mg/kg/day, maximum dose of 150 mg, anidulafungin
0.75 mg/kg/day, amphotericin B deoxycholate 0.5–1.0
mg/kg/day, or a lipid formulation of amphotericin
B 5 mg/kg/day for 14–21 days. |
Cystitis | Investigate possibility of disseminated disease. Remove catheter
if possible. Fluconazole, IV or PO, 6 mg/kg loading dose
followed by 3 mg/kg/day for total of 14 days,
amphotericin B deoxycholate 0.5 mg/kg/day for
3–10 days. |
Peritonitis (peritoneal dialysis catheter) | 5 fluorocytosine 50–150 mg/kg/day,
divided every 6 hours, and fluconazole, 6 mg/kg/day,
PO or IP, for 4–6 weeks. Remove catheter if no improvement
in 4–7 days. |
Candidemia | |
Uncomplicated | Fluconazole, IV, 6–12 mg/kg/day
(if resistant organisms not suspected), amphotericin B deoxycholate
0.5–1.0 mg/kg/day, caspofungin 70 mg/m2 loading
dose followed by 50 mg/m2/day,
or anidulafungin 1.5 mg/kg/day for a minimum of
14 days. Alternative therapies include voriconazole 14 mg/kg/day
IV divided every 12 hours or 400 mg/day PO divided every
12 hours, posaconazole 800 mg/day PO divided every 6 or
12 hours, or a lipid formulation of amphotericin B 5 mg/kg/day
for a minimum of 14 days. |
Catheter-related | Remove catheter. Treat as recommended above for uncomplicated
candidemia. Note that C tropicalis and C
parapsilosis may require treatment for up to 3–4
weeks. |
Disseminated and neutropenic patients | Amphotericin B deoxycholate 1.0 mg/kg/day,
lipid formulations of amphotericin B 5 mg/kg/day, caspofungin
70 mg/m2 loading dose followed by 50 mg/m2/day,
for 4–6 weeks (may be longer if clinically severe). Alternative therapy
includes fluconazole, voriconazole, micafungin, and anidulafungin,
although limited data in neutropenic patients. |
Coccidioidodes immitis5 | Nonmeningeal | Fluconazole, 6–12 mg/kg/day. Duration
not defined, suggest 12–18 months. Amphotericin B results
in similar cure rates in adults but should be considered in severely
ill or immunocompromised patients. Recommended total dose for adults
is 2.5 grams or higher. Lipid formulations of amphotericin B, itraconazole,
voriconazole, and posaconazole may also be effective. Uncomplicated
pulmonary disease in normal hosts may be monitored on no antifungal
therapy. |
Meningeal | Same as above but duration of therapy indefinite. |
Cryptococcus neoformans6 | Nonmeningeal | Mild to moderate pulmonary infections: fluconazole 12 mg/kg/day
or amphotericin B deoxycholate 0.5–1.0 mg/kg/day
with or without 5 fluorocytosine, 50–150 mg/kg,
divided every 6 hours. If amphotericin B is used initially, change
to fluconazole with improved clinical condition is possible after
a minimum of 2 weeks. Itraconazole, voriconazole, posaconazole,
and lipid formulations of amphotericin B may also be effective.
Total duration of therapy 6–12 months, based on clinical
course. Patients with HIV infection require chronic suppressive
therapy with fluconazole, 6 mg/kg, indefinitely. |
Meningeal | Same as for nonmeningeal but 5 fluorocytosine should be used.
Duration of amphotericin B plus 5 fluorocytosine 6 weeks, or 8–10
weeks of fluconazole. |
Dermatophytes Trichosporum (spp), Microsporum (spp), Epidermophyton (spp) | Tinea coporis, cruis, pedis | Topical clotrimazole or miconazole in cream, lotion, ointment,
or powder applied twice daily for 2–3 weeks. For failures,
consider other azole or allylamine preparation. Duration of therapy
2–3 weeks. |
Tinea capitis | Griseofulvin, 10 mg/kg/day ultramicrosized
or 15 mg/kg/day micosized, in 1 to 2 divided doses
or itraconazole 3–5 mg/kg/day for 4–6
weeks. |
Onychomycosis | Itraconazole 3–5 mg/kg/day for
3–4 months or itraconazole pulse therapy, 3–5
mg/kg/day for 1 week per month for 2 months or
terbinafine 250 mg (weight greater than 40 kg) or 125 mg (weight
20 to 40 kg) or 67.5 mg (weight less than 20 kg) for 6 weeks for
fingernail and 12 weeks for toenail disease. |
Malassezia furfur | Tinea versicolor | Ketoconazole cream or shampoo applied for 2 weeks or selenium
sulfide, leave on 10 minutes daily for 7 days or 3–5 times
weekly for 2–4 weeks. Successful therapy in adults with
ketoconazole 400 mg single dose or 200 mg daily for 7 days. |
Fusarium(spp)7-9 | Fungemia or disseminated infection | Voriconazole 14 mg/kg/day IV divided every
12 hours or 400 mg/day PO divided every 12 hours, amphotericin
B deoxycholate 1.0–1.5 mg/kg/day, lipid
formulation of amphotericin B 5 mg/kg/day, or
posaconazole 800 mg/day divided every 6 or 12 hours. Duration
of therapy undetermined but 6 weeks minimum. |
Histoplasma capsulatum10 | Pulmonary | No therapy in normal host for very mild or asymptomatic pulmonary
disease. Itraconazole 4–10 mg/kg/day divided
every 12 hours for mild to moderate infections, amphotericin B 0.5–1.0
mg/kg/day or lipid formulations of amphotericin
B 3–5 mg/kg/day for 1–2 weeks
followed by itraconazole, for a total of 12 weeks of therapy for
moderate to severe infections. |
Disseminated | Amphotericin B 0.5–1.0 mg/kg/day
or lipid formulations 3–5 mg/kg/day for
1–2 weeks followed by itraconazole for moderate to severe
infections. Itraconazole 4–10 mg/kg/day
divided every 12 hours for mild to moderate infections. Duration
of therapy is usually 12 months. HIV-infected patients require indefinite suppressive
therapy with itraconazole. |
Scedosporium(spp)7-9 | Fungemia or disseminated infection | Voriconazole 14 mg/kg/day IV divided every
12 hours or 400 mg/day PO divided every 12 hours or posaconazole
800 mg/day PO divided every 6 or 12 hours. S prolificans infections
can be treated with combination voriconazole plus terbinafine or
caspofungin. Duration of therapy is undetermined but 6 weeks minimum.
Surgical excision of lesion if feasible. Amphotericin B is ineffective. |
Sporothrix schenckii11 | Cutaneous | Itraconazole 8–10 mg/kg/day divided
every 12 hours for 3–6 months. |
Trichosporon(spp)8 | Fungemia or disseminated infection | Fluconazole 12 mg/kg/day. Voriconazole
may also be effective. Duration of therapy is undetermined but 6 weeks
minimum. |
ZygomycosesRhizopus (spp), Mucor (spp), Rhizomucor (spp), Cunninghamella bertholletiae7-9 | Rhinocerebral, pulmonary, and disseminated | Posaconazole 800 mg/day PO divided every 6 or 12
hours. Amphotericin B deoxycholate 1.0–1.5 mg/kg/day
or lipid formulations of amphotericin B 5 mg/kg/day.
Discontinuation of steroids. Surgical debridement recommended by
some experts. Duration of therapy is undetermined but 6 weeks minimum. |
Empiric therapy of presumed fungal infection in febrile neutropenic patients | | Amphotericin B deoxycholate 0.5–1.0 mg/kg/day
or lipid formulations of amphotericin B 3–5 mg/kg/day,
or caspofungin 70 mg/m2 loading dose followed
by 50 mg/m2/day. |