Medication Summary
Candidal infections are sensitive to a broad range of antifungal agents. Nystatin and one of the imidazoles are the most commonly used agents for oral or cutaneous candidiasis. Noting the resistance pattern in your area is important; fluconazole-resistant Candida has been reported. New antifungals include the echinocandins (eg, caspofungin, micafungin) with pediatric dosing approved by the US Food and Drug Administration (FDA). Another echinocandin, anidulafungin (Eraxis), is also approved, but does not have FDA-approved dosing for children. The mechanism of action of this group is to interfere with the cell wall integrity inhibiting 1,3 beta-D-glucan synthase. Many echinocandins have been approved by the US Food and Drug Administration (FDA). [62]
Topical antifungals (oral preparations)
Class Summary
These agents are used for the treatment of oral candidiasis (thrush).
Nystatin oral suspension (Nilstat)
Nystatin oral suspension is the drug of choice (DOC) for oral candidiasis. It is a fungicidal and fungistatic antibiotic obtained from Streptomyces noursei.
Topical antifungals (dermatologic)
Class Summary
These agents are used to treat cutaneous candidiasis.
Nystatin cream (Mycostatin, Nilstat)
Nystatin cream is the DOC in cutaneous candidiasis. Each gram of cream contains 100,000 U.
Clotrimazole 1% cream (Lotrimin, Mycelex)
Clotrimazole 1% cream is a second-line agent in the treatment of cutaneous candidiasis.
Miconazole topical (Absorbine, Micatin)
Miconazole topical is an alternate topical antifungal. Lotion is preferred in intertriginous areas. If cream is used, apply sparingly to avoid maceration effects.
Systemic antifungals (oral)
Class Summary
These agents are used for treatment of cutaneous infections refractory to treatment by topical agents or as adjunctive therapy for systemic candidal infection.
Fluconazole oral (Diflucan)
Fluconazole oral is a synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal CYP450 and sterol C-14 alpha-demethylation, which prevents conversion of lanosterol to ergosterol, thereby disrupting cellular membranes.
Itraconazole (Sporanox)
Itraconazole is an effective oral systemic antifungal, but is rarely used in pediatrics. It has fungistatic activity. Itraconazole is a synthetic triazole antifungal agent that slows fungal cell growth by inhibiting CYP450-dependent synthesis of ergosterol, a vital component of fungal cell membranes.
Ketoconazole (Nizoral)
Ketoconazole is a well-absorbed oral antifungal. Administer with food to reduce nausea and vomiting. It is an imidazole broad-spectrum antifungal agent. It inhibits synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.
Flucytosine (Ancobon)
Flucytosine is also known as 5-FC. It is converted to fluorouracil after penetrating fungal cells. It inhibits RNA and protein synthesis and is active against Candida and Cryptococcus species and generally used in combination with amphotericin B, never alone due to concern for resistance.
Posaconazole (Noxafil)
Posaconazole is a triazole antifungal agent. It blocks ergosterol synthesis by inhibiting the enzyme lanosterol 14-alpha-demethylase and sterol precursor accumulation. This action results in cell membrane disruption. It is available as an oral suspension (200 mg/5 mL). It is indicated for prophylaxis of invasive Aspergillus and Candida infections in patients at high risk due to severe immunosuppression.
Voriconazole oral (Vfend)
Voriconazole oral is used for primary treatment of invasive aspergillosis and salvage treatment of Fusarium species or Scedosporium apiospermum infections. It is a triazole antifungal agent that inhibits fungal CYP450-mediated 14 alpha-lanosterol demethylation, which is essential in fungal ergosterol biosynthesis. It may be used as combination therapy for Candidemia. It is also used for prophylaxis in high-risk groups.
Systemic antifungals (intravenous)
Class Summary
The mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal cell.
Fluconazole IV (Diflucan)
Fluconazole IV is a second-line agent for the treatment of systemic candidal infection in neutropenic patients.
Amphotericin B, liposome (AmBisome)
Amphotericin B in a 10% lipid emulsion appears to have less nephrotoxicity than the standard preparation of amphotericin. Lipid emulsion does not appear to decrease antifungal properties of amphotericin B.
Amphotericin B desoxycholate (Amphocin, Fungizone)
Amphotericin B desoxycholate is an important treatment of systemic fungal infections, especially molds. It has been replaced by the azoles and echinocandins as first-line therapy. It is a polyene antibiotic produced by a strain of Streptomyces nodosus; it can be fungistatic or fungicidal. It binds to sterols (eg, ergosterol) in the fungal cell membrane, causing intracellular components to leak, with subsequent fungal cell death.
Premedication with acetaminophen may help reduce rigors, chills, and fever associated the with infusion. Hydrocortisone directly added to infusate also may reduce febrile reactions.
Caspofungin (Cancidas)
Caspofungin is the first of a new class of antifungal drugs (glucan synthesis inhibitors). It inhibits synthesis of beta-(1,3)-D-glucan, an essential component of fungal cell wall. It is the DOC for systemic candidiasis in neutropenic or sick patients.
Voriconazole IV (Vfend)
Voriconazole IV is used for the primary treatment of invasive aspergillosis and salvage treatment of Fusarium species or Scedosporium apiospermum infections. It is a triazole antifungal agent that inhibits fungal CYP450-mediated 14 alpha-lanosterol demethylation, which is essential in fungal ergosterol biosynthesis. It may be used as combination therapy in Candidemia.
Micafungin (Mycamine)
Micafungin is a semisynthetic lipopeptide (echinocandin) antifungal agent that inhibits cell wall synthesis. It is indicated for use in children as young as 4 months to treat candidemia, acute disseminated candidiasis, candidal peritonitis and abscesses, esophageal candidiasis, and prophylaxis of candidal infections in hematopoietic stem cell transplant (HSCT) recipients. For children younger than 4 months, it is indicated for treatment of candidemia, acute disseminated candidiasis, and candidal peritonitis and abscesses without meningoencephalitis and/or ocular dissemination.
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Typical appearance of thrush. Note multiple white plaques on lips, gingivae, tongue, and palate.
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Candidal diaper dermatitis. Note satellite papules and involvement of intertriginous folds.
