17.4 Invasive Fungal Infections
| Type of Infection | First Line (with Dosage and Duration) |
Alternative First Line (with dosage and Duration) |
Comments |
|---|---|---|---|
| Invasive Candidiasis | Echinocandins (caspof ungin, anidulafungin, or micafungin) are recommended as first- line agents Micafungin 100 mg IV daily/ Anidulafungin loading dose 200 mg, then 100 mg daily/ Caspofungin loading dose 70 mg, then 50 mg daily | Liposomal Amphotericin B 3–5 mg/kg daily | Repeat culture to be done to look for clearance of candidemia, by 3rd day of antifungal treatment. Duration of therapy: 14 days of antifungal therapy is recommended after the first negative blood culture post antifungal therapy. Central venous catheters (CVCs) should be removed as early as possible when the source is presumed to be the CVC. Transition from echinocandin to fluconazole is recommended after 5–7 days amongst patients who have isolates that are susceptible to fluconazole, who are clinically stable, and in whom repeat cultures while on antifungal therapy are negative. |
| Invasive aspergillosis | Voriconazole (6mg/kg X 2 doses Followed by 4 mg/kg q12h) Or Isavuconazole 200mg TDS for 6 doses and 200mg OD | Posaconazole 300 mg twice on day 1, followed by 300 mg OD Or Liposomal Amphotericin B 3 to 5 mg/kg/day OD | Duration is 6-12 weeks but prolonged treatment may be required depending on the site of infection and resolution of symptoms. Therapeutic Dose Monitoring (TDM) of voriconazole/posaconazole is recommended. |
| Mucormycosis | Liposomal Amphotericin B: 5 to 10 mg/kg/day OD (concomitant administration with other nephrotoxic drugs should be avoided) | Isavuconazole 200mg TDS for 2 days and 200mg OD Or Posaconazole 300 mg twice on day 1, followed by 300 mg OD | Surgical debridement at the earliest to the extent possible Amphotericin deoxycholate (1- 1.5mg/kg/day) is an alternative option to liposomal amphotericin B, though less preferred due to increased adverse events. Nephrotoxicity may be reduced by prehydration with Normal Saline and by administering Amphotericin B deoxycholate at rate 0.08mg/kg/hour. Duration of therapy for mucormycosis is difficult to define, but in general 2 weeks, after complete surgical debridement is advised. If complete surgical debridement is not done or not possible then therapy should be continued till radiological resolution. |
For common etiological agents of Invasive Fungal Infections, see Annexure B.17.4
References
1. Peter G. Pappas, Carol A. Kauffman, David R. Andes, Cornelius J. Clancy, Kieren A. Marr, Luis Ostrosky-Zeichner, et al, Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 62, Issue 4, 15 February 2016, Pages e1–e50, https://doi.org/10.1093/cid/civ933
2. Thomas F. Patterson, George R. Thompson, David W. Denning, Jay A. Fishman, Susan Hadley, Raoul Herbrecht, Dimitrios P. Kontoyiannis, Kieren A. Marr, Vicki A. Morrison, M. Hong Nguyen, Brahm H. Segal, William J. Steinbach, David A. Stevens, Thomas J. Walsh, John R. Wingard, Jo- Anne H. Young, John E. Bennett, Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 63, Issue 4, 15 August 2016, Pages e1– e60, https://doi.org/10.1093/cid/ciw326
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