Anti-Fungal Agents Used in Pediatrics
Classification of Antifungal Agents
1. Azoles: Fluconazole, Itraconazole, Voriconazole
2. Polyenes: Amphotericin B, Nystatin
3. Echinocandins: Caspofungin
4. Allylamines: Terbinafine
5. Other Antifungals: Griseofulvin
Fluconazole
Indications: Treatment of candidiasis, cryptococcal meningitis, prophylaxis in immunocompromised patients.
Dosage:
- Candidiasis: 6-12 mg/kg/day (depending on severity).
- Cryptococcal meningitis: 12 mg/kg on the first day, then 6-12 mg/kg/day.
Contraindications: Hypersensitivity to fluconazole or other azoles.
Adverse Effects: Nausea, headache, abdominal pain, rash.
Special Note: Use with caution in patients with renal or hepatic impairment; monitor liver function tests.
Amphotericin B
Indications: Treatment of severe systemic fungal infections (e.g., aspergillosis, cryptococcosis, mucormycosis).
Dosage:
- 0.25-1 mg/kg/day (depending on formulation and severity of infection).
Contraindications: Hypersensitivity to amphotericin B.
Adverse Effects: Nephrotoxicity, infusion-related reactions (fever, chills), electrolyte imbalances.
Special Note: Monitor renal function and electrolytes closely; liposomal formulations are less nephrotoxic.
Caspofungin
Indications: Treatment of invasive candidiasis, aspergillosis (refractory to other treatments).
Dosage:
- Loading dose: 70 mg/m² on day 1, then 50 mg/m²/day (max 70 mg/day).
Contraindications: Hypersensitivity to caspofungin.
Adverse Effects: Fever, phlebitis, hepatic effects, rash.
Special Note: Adjust dose in patients with moderate hepatic impairment; monitor liver function.
Itraconazole
Indications: Treatment of systemic mycoses (e.g., histoplasmosis, blastomycosis), onychomycosis.
Dosage:
- 5-10 mg/kg/day (divided into two doses).
Contraindications: Hypersensitivity to itraconazole or other azoles, heart failure.
Adverse Effects: Nausea, vomiting, headache, hepatic toxicity.
Special Note: Monitor liver function tests; absorption is increased with food and acidic beverages.
Voriconazole
Indications: Treatment of invasive aspergillosis, candidemia, serious fungal infections caused by Scedosporium and Fusarium species.
Dosage:
- Loading dose: 6 mg/kg every 12 hours for 2 doses, then 4 mg/kg every 12 hours.
Contraindications: Hypersensitivity to voriconazole or other azoles.
Adverse Effects: Visual disturbances, hepatotoxicity, rash, nausea.
Special Note: Monitor liver function and renal function; adjust dose in hepatic impairment.
Griseofulvin
Indications: Treatment of dermatophytosis (ringworm, athlete’s foot, jock itch).
Dosage:
- 10-20 mg/kg/day (in single or divided doses).
Contraindications: Hypersensitivity to griseofulvin, severe liver disease, porphyria.
Adverse Effects: Headache, nausea, vomiting, photosensitivity, rash.
Special Note: Best absorbed with fatty foods; avoid in patients with severe liver impairment.
Nystatin
Indications: Treatment of cutaneous, oral, and intestinal candidiasis.
Dosage:
- Oral candidiasis: 100,000 units/ml suspension, 1-2 ml four times daily.
- Cutaneous candidiasis: Apply cream or ointment two to three times daily.
Contraindications: Hypersensitivity to nystatin.
Adverse Effects: Rarely causes gastrointestinal upset or skin irritation.
Special Note: Oral suspension should be swished and swallowed for oral candidiasis.
