Treatment of Fungal Infections

First-Line Treatment

The Infectious Diseases Society of America (IDSA) recommends an echinocandin (caspofungin, micafungin, or anidulafungin) as the first-line treatment for Candida infections, with fluconazole as an alternative for susceptible species 1, 2
Echinocandins are the preferred first-line agents for invasive candidiasis in patients with hepatitis, according to the IDSA 1
Initial therapy with an echinocandin is recommended in critically ill patients with systemic symptoms, as suggested by the IDSA 3

Fluconazole is recommended at a dose of 400-800 mg (6-12 mg/kg) daily for fluconazole-susceptible Candida species, and can be considered for step-down therapy after initial echinocandin treatment if the isolate is susceptible 1, 2
Amphotericin B deoxycholate is an alternative treatment option, administered at a dose of 0.3-0.6 mg/kg daily for 1-7 days with or without oral flucytosine 25 mg/kg 4 times daily 1
Lipid formulations of amphotericin B at a dose of 3-5 mg/kg/day IV, with minimal hepatic metabolism, are recommended by the Centers for Disease Control and Prevention 4

Antifungal therapy should be continued for at least 14 days after the last positive culture, and longer treatment may be necessary for persistent candidemia or complicated intra-abdominal infections 1
Source control, including surgical intervention or drainage of infected ascites, is strongly recommended when feasible 1, 2
Central venous catheter removal is strongly recommended if present, and adequate drainage is critical to successful therapy if there are collections or abscesses, as recommended by the IDSA and the Journal of Microbiology, Immunology and Infection 1, 5

The severity of illness and risk factors for fluconazole resistance should be considered when selecting therapy, with echinocandins strongly preferred as initial therapy 1, 2
The IDSA recommends considering the following dosages:
Medication Dosage
Caspofungin 70 mg loading dose, then 50 mg daily IV
Anidulafungin 200 mg loading dose, then 100 mg daily IV
Micafungin 100 mg daily IV
6, 1, 4
Special Populations
For fluconazole-resistant Candida species, an echinocandin may be necessary, as recommended by the IDSA 3
For C. albicans infections, fluconazole is an appropriate first-line treatment, as recommended by the IDSA 3
For C. glabrata infections, consideration should be given to using amphotericin B deoxycholate or an echinocandin due to frequent resistance to fluconazole, as stated in the Clinical Infectious Diseases journal 3, 7
For C. krusei infections, echinocandin or liposomal amphotericin B may be used as an alternative treatment option, as recommended by the American College of Physicians and the IDSA 8, 9
The recommended first-line treatment for fungal infections in children is fluconazole 8-12 mg/kg/day orally, with dosing adjusted based on infection site and severity, as recommended by the IDSA and the American Academy of Pediatrics 10, 9

Medication	Dosage
Caspofungin	70 mg loading dose, then 50 mg daily IV
Anidulafungin	200 mg loading dose, then 100 mg daily IV
Micafungin	100 mg daily IV

Clotrimazole 1% cream applied twice daily for 2-4 weeks is recommended by the Centers for Disease Control and Prevention for Candida infections 11
Topical azole (clotrimazole 1% cream) applied twice daily for 2-4 weeks is an alternative treatment for mild cases of fungal infections in children, although the evidence is not as strong as for fluconazole 10

Severe fungal wound infections can be treated with systemic voriconazole (loading dose 400 mg twice daily for 2 doses, then 200 mg twice daily), with surgical intervention including aggressive debridement of infected and necrotic tissue 5
Wound care should include thorough mechanical cleansing followed by application of antifungal, with dressings that allow daily inspection and maintain a moist wound environment, as recommended by the Journal of Microbiology, Immunology and Infection and the IDSA 5, 1

Keeping affected areas clean and dry, drying thoroughly after bathing, especially in skin folds, and applying separate towels for drying the groin and other body parts to prevent contamination, as recommended by the American Academy of Pediatrics 12
Maintenance therapy with weekly fluconazole 150 mg for 6 months may be considered for recurrent infections, as recommended by the IDSA, based on the Clinical Infectious Diseases journal 7
Addressing all predisposing factors, such as diabetes mellitus, obesity, and immunosuppression, is crucial in managing recurrent infections, according to the Clinical Infectious Diseases journal 7