This page summarizes primary and alternative drugs for the treatment of specific fungal infections. This page focuses on medical therapeutic approaches and it must be remembered that other therapeutic measures (most commonly, surgical excision and debridement) are required in combination with antifungal therapy for some fungal infections. Please refer to the related page about each fungal infection for additional data.
Please also see our discussion on cost analysis and pharmacoeconomic analysis of antifungal therapy.
The tables are presented in two sections. The first table shows drugs of choice and the second table shows suitable dosages. These abbreviations are used throughout the tables:
- AMB: Amphotericin B deoxycholate (Fungizone)
- ABLC: Amphotericin B lipid complex (Abelcet)
- ABCD: Amphotericin B colloidal dispersion (Amphotec)
- LAMB: Liposomal amphotericin B (AmBisome)
- Echinocandin: Caspofungin, micafungin or anidulafungin
Drugs of Choice
The following table summarizes the therapeutic options in the more frequent systemic fungal infections [85, 99, 114, 291, 421, 525, 795, 946, 1000, 1001, 1003, 1168, 1406, 1623, 1737, 1915, 1934, 1993, 2163, 2290, 2415]. Some of the treatment modalities have not been formally approved by the US Food and Drug Administation.
| MYCOSES | DRUG OF CHOICE | ALTERNATIVE(S) |
|---|---|---|
| Aspergillosis | Voriconazole | Itraconazole |
| An AMB preparationa | Echinocandin | |
| Itraconazole (used in milder forms or after more severe disease is stabilized with an AMB preparation)a | Posaconazole | |
| Blastomycosis | An AMB preparationa | Ketoconazole |
| Itraconazole capsule (for mild to moderate disease) | Fluconazole PO | |
| Candidiasisb | ||
| Candidemia and invasive candidiasis | Echinocandin
An AMB preparationa |
ABLC |
| Fluconazoleb IV or PO | ABCD
LAMB |
|
| Oropharyngeal candidiasis | Fluconazoleb PO | Ketoconazole
Itraconazole Clotrimazole troche Nystatin oral suspension AMB oral suspension AMB IVc |
| Esophageal candidiasis | Fluconazoleb PO | Ketoconazole
Itraconazole AMB IVc Echinocandind |
| Vulvovaginal candidiasis | Fluconazoleb, e PO single dose | Ketoconazole |
| Topical azole preparations | Itraconazole | |
| Nystatin vaginal tablet | Boric acid | |
| Coccidioidomycosis | An AMB | Ketoconazole |
| preparationa (for rapidly progressive disease) | Itraconazole
Voriconazole Posaconazole |
|
| Fluconazole PO or IV (for subacute/chronic disease or coccidioidal meningitis) | AMB intrathecalf | |
| Cryptococcosis | An AMB preparationa+Flucytosine | LAMB
Voriconazole Posaconazole |
| Chronic suppressive therapy with fluconazole PO in AIDS patients (lifelong) | Itraconazole capsule
Chronic suppressive therapy with itraconazole capsule or AMB (weekly) in AIDS patients (lifelong) |
|
| Dermatophytosisg (other than dermatophytic onychomycosis) | Terbinafine | Griseofulvin |
| Itraconazole capsule | Fluconazole Topical therapy | |
| Histoplasmosis | AMB (for severe disease) | ABLC |
| Itraconazole (for mild to moderate disease) | ABCD
LAMB Ketoconazole Fluconazole |
|
| Chronic suppressive therapy with itraconazole capsule in AIDS patients (lifelong) | Chronic suppression therapy with itraconazole capsule, fluconazole PO or AMB (weekly) in AIDS patients (lifelong) | |
| Onychomycosis | ||
| Candida onychomycosis | Itraconazole capsule | |
| Dermatophytic onychomycosis | Terbinafine | Griseofulvin |
| Itraconazole oral capsule | Topical cicloprox olamine
Fluconazole |
|
| Paracoccidioidomycosis | An AMB preparationa Itraconazole (for mild to moderate disease) |
Ketoconazole |
| Pseudallescheriasis | Voriconazole
Itraconazole Ketoconazole Posaconazole |
|
| Sporotrichosis | ||
| Cutaneous and lymphocutaneous sporotrichosis | Itraconazole | Potassium iodide
Fluconazole PO |
| Systemic sporotrichosis | An AMB preparationa (for severe disease)
Itraconazole (for mild to moderate disease) Chronic suppressive therapy with itraconazole capsule in AIDS patients (lifelong) |
Fluconazole PO |
| Zygomycosis | An AMB preparationa | Posaconazole |
a. The lipid formulations of amphotericin B are licensed for use in patients whose infection is intolerant or refractory to amphotericin B deoxycholate treatment. However, a lipid AMB (ABLC, ABCD, or LAMB) can generally be substituted and is often preferred for mould infections.
b. Fluconazole should not be used in any clinical form of candidiasis due to Candida krusei as this species is felt to be intrinsically resistant to fluconazole. For other Candida spp., such as Candida glabrata, in vitro antifungal susceptibility test results may be used to determine whether the infecting strain is susceptible to fluconazole. See our discussion of the usual susceptibility patterns of Candida spp.
c. Indicated only in azole-refractory or azole-resistant infections.
d. Caspofungin has activity here, but is not licensed for this indication. Limited safety data exist for caspofungin and the risk/benefit ratio for its use here would need to be carefully evaluated.
e. 150 mg single dose therapy.
f. May be indicated in patients who do not respond to fluconazole.
g. In patients with widespread skin lesions and tinea capitis, oral therapy is indicated since topical therapy frequently fails.
Dosages
Below are the generally recommended doses of systemically administered antifungal agents. The optimal dose may need to be modified depending on the severity of the infection as well as the immune status of the host. Thus, the recommendations below are not strict and their use requires cautious individual evaluation of each patient.
| DRUG | USUAL DOSE |
|---|---|
| AMB | 0.6-1.5 mg/kg/day IV (doses above 1 mg/kg/d tend to be highly nephrotoxic and must be administered with great caution) 10 µg intravitreal Oral suspension 100 mg (1 ml) four times daily |
| ABCD | 3-4 mg/kg/day IV |
| ABLC | 5 mg/kg/day IV |
| LAMB | 3-6 mg/kg/day IV |
| Boric acid | 600 mg gelatin capsule once daily intravaginal |
| Caspofungin | Loading dose of 70 mg/day, followed by 50 mg/day IV
50-150 mg/day Loading dose of 100-200 mg/day, followed by 50-100 mg/day |
| Clotrimazole troche | 10 mg five times daily PO |
| Fluconazole | 100-800 mg once/bid PO 150 mg PO single dose therapy (for vulvovaginal candidiasis) 400-800 mg IV |
| Flucytosine | 25 mg/kg qid PO |
| Griseofulvin | 10-20 mg/kg/day PO tablet/syrup |
| Itraconazole | 200-400 mg capsule once/bid PO Oral solution 200 mg (20 ml) once daily |
| Voriconazole | 6 mg/kg q12h day#1, the 3-4 mg/kg/q12h IV 200 mg qid PO |
| Posaconazole | 800 mg/day PO divided doses (bid-qid) |
| Ketoconazole | 400-800 mg once/bid PO |
| Nystatin | 500,000 U (5 ml) oral suspension four times daily PO 100,000 U vaginal tablet once daily |
| Potassium iodide (saturated solution) | 1-5 ml tid PO |
| Terbinafine | 250 mg/day PO |