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Infectious Disease - Antifungals

Antifungals  See updated page HERE
Ampho B:
Test dose: (optional): 1 mg/20-50 ml D5W over 10-30 minutes. Monitor temp, pulse, RR and BP q30min x 4 hours. Do not give premeds with test dose.

Maintenance dose: Initially give 0.25-0.3 mg/kg/day. Increase as tolerated by an equivalent amount once daily. Usual daily dose: 0.5-1 mg/kg/day or up to 1.5 mg/kg every other day. For life-threatening infection may give full dose the first day (usually 0.6-0.7 mg/kg IBW on Day # 1).   Premedication: Prevention of fever/chills: Tylenol 650mg PO/PR + Benadryl 25-50mg PO/IVP  60min prior to maintenance infusion. May also add: Hydrocortisone 25-50mg IV/IM +/- Demerol 50mg IV.

Renal dosing: <10/ q24-36h. During therapy if the BUN increases above 40 mg/dl or the serum creatinine exceeds 2.5-3 mg/dl, Hold Ampho B until renal function improves, then restart at a reduced dose or change to every other day dosing until  the serum creatinine/BUN improve.

Bladder irrigation: Add 30-50mg Ampho B to 1000ml (or less) sterile H2O administered intermittently or continuously for 2 to 14 days. (Note: use of D5W for Bladder irrigations is not recommended because of the possibility of enhancing microbial and fungal growth in the bladder).
Ampho B lipid (Albecet ®): 5 mg/kg/day IV.
Clotrimazole (Mycelex ®): Oral troches 5 x/day x 14 days.
fluconazole
(Diflucan ®)		 Vaginal candidiasis: 150 mg x 1. Systemic candidiasis: 400 mg orally or IV once daily.   Esophageal candidiasis: 100-200 mg orally once daily (up to 400mg/day).  Cryptococcal meningitis: 400mg orally x 1, followed by 200mg  once a day x 10-12 weeks  (Suppression: 50-200mg orally once daily). Onychomycosis: 200-300mg once a week or 100-200mg orally every other day  (further studies needed).    IV: since oral absorbtion is rapid and essentially complete--IV dose=oral dose.
flucytosine (Ancobon ®):  50-150 mg/kg/day orally in 4 divided doses.
Griseofulvin:  microsize: tinea: 11 mg/kg up to 500 mg orally once daily.
Itraconazole (Sporanox ®): Systemic mycosis: 200mg orally once daily with food (up to maximum of 400mg/day if unsatisfactory clinical response with lower dose).  Doses >200mg are given in 2 divided doses. Onychomycosis: 200mg orally twice daily for 1 week each month for  2 months (fingernails);   x 3-4 months (toenails).   Oropharyngeal candidiasis: 200mg (20ml)-oral solution-swish vigorously then swallow once daily x 1-2 weeks. Esophageal candidiasis: 100mg (10ml) oral solution--swish and swallow once daily x 3 weeks. May increase to 200mg/day. Life-threatening infections: Loading dose: 200mg orally 3 times daily should be given for the first 3 days of therapy, then 200-400mg/day.
ketoconazole (Nizoral ®): 200-400 mg orally once daily.
nystatin (Mycostatin ®): Thrush: 4 to 6 ml orally (swish/swallow)  4 times a day.
terbinafine (Lamisil ®):  Superficial mycoses(tinea corporus, cruris, pedis, capitis; cutaneous candidiasis): 250 mg orally once daily. Onychomycosis: (fingernails) 250mg orally once daily x 6 weeks or pulse dosing: 500mg orally once daily for 1st week of month x 2 months. (Toenails): 250mg orally once daily x 12 weeks  or  pulse dosing: 500mg once daily for 1st week of month x 4 months. Systemic mycosis: 250-500mg orally once daily.

Topical Antifungals
butenafine (Mentax ®) Apply cream once or twice daily. [cream 1%]
ciclopirox (Loprox ®):  Apply cream or lotion twice daily  [cream/lotion 1%]
clotrimazole (Lotrimin ®): Apply twice daily.   Supplied:  [1% cream /solution /lotion]
enconazole (Spectazole ®):  Tinea: apply once daily. Candida: apply twice daily.   Supplied:[1% cream]
ketoconazole: 
(Nizoril ®) 		 Tinea/candida: apply once a day  Supplied: [2% cream]. Seborrheic dermatitis: apply shampoo/cream  once or twice daily. Dandruff: shampoo 2 times per week.
Miconazole: Tinea/candida: apply twice a day.  Supplie:  [2% cream/powder/spray]
naftifine 
(Naftin ®): 		 Tinea: apply once daily (cream) or  twice a day- (gel)
nystatin: candidiasis: apply 2 to 3 times daily.   Supplied: [cream / powder/ ointment]
oxiconazole (Oxistat ®):  Tinea: apply once or twice daily.   Supplied: [cream/lotion 1%]
terbinafine (Lamisil ®): Tinea: apply once or twice daily.   Supplied: [cream 1%]
tolnaftate (Tinactin ®):  Apply twice a day.  Supplied:  [1% cream /powder/ gel /solution]

References - Infectious Disease Section
American Hospital Formulary Service.  Drug Information. Bethesda, MD: ASHP, 1997.
Baden LR, Eisenstein BI.Impact of Antibiotic Resistance on the Treatment of Gram-negative Sepsis. Curr Infect Dis Rep. 2000 Oct;2(5):409-416.
Bartlett JG et al. Community-acquired pneumonia in adults: guidelines for management. Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 1998;26:811-38.
Bartlett JG: Empirical therapy of community-acquired pneumonia: macrolides are not ideal choices. Semin Respir Infect 1997 Dec; 12(4): 329-33
Bartlett JG.1998 Pocket Book of Infectious Disease Therapy., Ninth Edition. Baltimore,MD: Williams&Wikins,1998.
Bernstein JM: Treatment of community-acquired pneumonia--IDSA guidelines. Infectious Diseases Society of America. Chest 1999 Mar; 115(3 Suppl): 9S-13S
Drug Information Handbook, 5th Ed. 1997, Lexi-Comp inc. 
Ewig S et al. Pneumonia acquired in the community through drug-resistant Streptococcus pneumoniae. Am J Respir Crit Care Med. 1999;159:1835-42.
File TM Jr. Community-acquired pneumonia: recent guidelines for therapy. J Respir Dis. 1999;20:534-41.
Gilbert DN, Moellering RC, Sande MA. The Sanford Guide to Antimicrobial Therapy 2000. 30th ed. Hyde Park,VT: Antimicrobial Therapy, Inc.; 2000.
Gold HS, Moellering RC. Antimicrobial-drug resistance. N Engl J Med. 1996;335:1445-1453.
Gonzales R, Sande M: What will it take to stop physicians from prescribing antibiotics in acute bronchitis? Lancet 1995 Mar 18; 345(8951): 665-6
Hooton TM, Stamm WE. Diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am 1997;11:551-581.
Lipsky BA, Berendt AR.Principles and practice of antibiotic therapy of diabetic foot infections. Diabetes Metab Res Rev. 2000 Sep-Oct;16 Suppl 1:S42-6.
Mufson MA.Pneumococcal Pneumonia.
Curr Infect Dis Rep. 1999 Apr;1(1):57-64.
Reese RE, Betts RF: A Practical Approach to Infectious Diseases. 4th ed. Boston: Little, Brown, and Company; 1996: 251
Stefani SD, Cadore LP, Villaroel RU, Azevedo S, Machado AL. Antibiotic Selection in the Treatment of Febrile Neutropenia: Current Approach and New Directions.
Braz J Infect Dis. 1998 Jun;2(3):109-117.
Stamm WE, Hooton TM. Management of urinary tract infections in adults. N Engl J Med 1993;329:1328-1334.

Disclaimer
All calculations must be confirmed before use. The authors make no claims of the accuracy of the information contained herein; and these suggested doses are not a substitute for clinical judgement. Neither GlobalRPh Inc. nor any other party involved in the preparation of this program shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material.PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER.   Read the disclaimer

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