Medication Summary

Antifungal antibiotics, frequently used in combination, are the mainstay of treatment of fungal endocarditis (FE). Fluconazole therapy has been less successful than other agents.^[17]In almost all reported cases of survival, surgical management was necessary to supplement antifungal medical therapy. Studies suggest that fluconazole prophylaxis may help to prevent invasive fungal infections, including endocarditis, in the newborn population.^[18]

Class Summary

The mechanism of action may involve increasing the permeability of the cell membrane, which, in turn, causes intracellular components to leak, alteration of RNA and DNA metabolism, or an intracellular accumulation of peroxide that is toxic to the fungal cell.

Amphotericin B (AmBisome, Abelcet)

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DOC for severe fungal infections. Fungicidal or fungistatic (depending on the organisms); best-studied drug, despite its toxicities. Although few data are available, use of one of lipid formulations (ie, lipid complex, liposome) at comparable doses is recommended.

Flucytosine (Ancobon)

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Adjunct to amphotericin B that seems to have a synergistic therapeutic effect in severe fungal infections. Converted to fluorouracil after penetrating fungal cells. Inhibits RNA and protein synthesis. Active against candidal and cryptococcal infections and generally used in combination with amphotericin B.

Fluconazole (Diflucan)

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Although it has fewer toxicities than the preceding drugs, insufficient data and concerns about efficacy keep fluconazole a second-line drug for this infection.

Caspofungin (Cancidas)

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Used to treat refractory invasive aspergillosis and poorly responsive or nonresponsive yeast infections. First of a new class of antifungal drugs (glucan-synthesis inhibitors). Inhibits synthesis of 1,3-beta-D-glucan, an essential component of fungal cell wall.

Voriconazole (Vfend)

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Used for primary treatment of invasive aspergillosis and salvage treatment of Fusarium species or Scedosporium apiospermum infections. A triazole antifungal agent that inhibits fungal cytochrome P450-mediated 14 alpha-lanosterol demethylation, which is essential in fungal ergosterol biosynthesis. Posaconazole may become available as a similar, but potentially safer, alternative.

Micafungin (Mycamine)

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Member of new class of antifungal agents, echinocandins, which inhibit cell wall synthesis. Inhibits synthesis of 1,3-beta-D-glucan, an essential fungal cell wall component not present in mammalian cells.

Indications include (1) prophylaxis of Candida infections in patients undergoing hematopoietic stem cell transplantation and (2) treatment of esophageal candidiasis.

Anidulafungin (Eraxis)

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Antifungal agent of the echinocandin class. Inhibits synthesis of 1,3-beta-D-glucan, an essential component of fungal cell walls. Indicated to treat esophageal candidiasis, candidemia, and other forms of candidal infections (eg, intraabdominal abscesses, peritonitis).

Posaconazole (Noxafil)

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Triazole antifungal agent. Blocks ergosterol synthesis by inhibiting the enzyme lanosterol 14-alpha-demethylase and sterol precursor accumulation. This action results in cell membrane disruption. Available as PO susp (200 mg/5 mL). Indicated for prophylaxis of invasive Aspergillus and Candida infections in patients at high risk because of severe immunosuppression.

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Media Gallery

Candida albicans vegetation (blue arrow) in the left atrium and attached to the intra-atrial septum in a 24-week estimated gestational age newborn (courtesy of Albert Santos and Dr. Sumekala Nadaraj, New Brunswick, NJ).
Candida albicans vegetation (blue arrow) in the left atrium and attached to the intra-atrial septum in a 24-week estimated gestational age newborn (courtesy of Albert Santos and Dr. Sumekala Nadaraj, New Brunswick, NJ).