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Chapter 247. Antifungal Therapy

Patricia M. Flynn

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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.

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Table 247-1. Antifungal Therapy
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Table 247-1. Antifungal Therapy
Organism or ConditionDiseaseTherapy
Aspergillus(spp)1Invasive, central nervous system, or sinus infectionVoriconazole 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.
SkinSurgical 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 dermatitidis2Pulmonary and disseminatedAmphotericin 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)3,4Oropharyngeal 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.
CutaneousNystatin or clotrimazole or miconazole cream, lotion, or powder applied twice a day for at least 7 days.
VaginitisTopical 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.
EsophagitisFluconazole, 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 ...

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