Practical considerations for individualized selection of antifungal agents for patients with A-Leuk
Factors . | Setting . | Agent of choice, alternatives, and route . |
---|---|---|
Host-related | ||
Hemodynamic instability | Hematogenous candidiasis | Echinocandin; fluconazole and L-AMB as alternatives |
Organ dysfunction, severe | ||
Gastrointestinal tract | Mucositis, nausea, vomiting, diarrhea, poor adherence, drug-food interaction | IV route |
Kidneys | Tumor lysis syndrome | Azoles, echinocandin; avoid amphotericin B products |
Liver | Echinocandin, L-AMB, ABLC; avoid azoles | |
Drug-related | ||
Drug-drug interaction | Chemotherapy administration | Echinocandin, L-AMB, ABLC; avoid mold-active triazoles |
Drug-food interaction | Food intake | Echinocandin, L-AMB, fluconazole IV; food intake may alter absorption of azoles |
Breakthrough infection | Infection while on antifungal agent | Use different class of antifungal agents |
Cost and convenience | Outpatient setting | Oral route always preferable to IV if gut function intact |
Select agent with longest dosing interval | ||
Infection-related | ||
Site of infection | Urinary | Fluconazole: only agent with urinary concentrations |
Ocular | Triazoles, L-AMB; avoid echinocandins (poor distribution) | |
CNS | Triazoles, L-AMB; avoid echinocandins (poor distribution) | |
Pathogen | ||
Candida species | Disseminated, acute and chronic | Echinocandin, fluconazole, L-AMB |
C krusei | Disseminated, acute and chronic | Echinocandin, L-AMB; avoid fluconazole |
C glabrata | Disseminated, acute and chronic | Echinocandin, L-AMB, voriconazole; avoid fluconazole |
C parapsilosis | Disseminated, acute and chronic | L-AMB, voriconazole; avoid echinocandins |
Trichosporon spp | Disseminated, acute and chronic | Fluconazole, other azoles; amphotericin B not effective |
Aspergillus spp | Sinus, pulmonary, disseminated | Voriconazole, L-AMB, ABLC; no role for fluconazole |
Aspergillus flavus | Sinus, pulmonary, disseminated | Voriconazole; posaconazole alternative |
Fusarium spp | Sinus, pulmonary, cellulitis, disseminated | L-AMB, ABLC; voriconazole maintenance if susceptible |
Scedosporium apiospermum | Sinus, pulmonary, ocular, CNS, bone and soft tissues, disseminated | Voriconazole; posaconazole alternative |
Black molds | Various sites | Voriconazole; posaconazole alternative |
Agents of mucormycosis | Sinus, pulmonary, disseminated | L-AMB, ABLC; posaconazole maintenance if susceptible |
Factors . | Setting . | Agent of choice, alternatives, and route . |
---|---|---|
Host-related | ||
Hemodynamic instability | Hematogenous candidiasis | Echinocandin; fluconazole and L-AMB as alternatives |
Organ dysfunction, severe | ||
Gastrointestinal tract | Mucositis, nausea, vomiting, diarrhea, poor adherence, drug-food interaction | IV route |
Kidneys | Tumor lysis syndrome | Azoles, echinocandin; avoid amphotericin B products |
Liver | Echinocandin, L-AMB, ABLC; avoid azoles | |
Drug-related | ||
Drug-drug interaction | Chemotherapy administration | Echinocandin, L-AMB, ABLC; avoid mold-active triazoles |
Drug-food interaction | Food intake | Echinocandin, L-AMB, fluconazole IV; food intake may alter absorption of azoles |
Breakthrough infection | Infection while on antifungal agent | Use different class of antifungal agents |
Cost and convenience | Outpatient setting | Oral route always preferable to IV if gut function intact |
Select agent with longest dosing interval | ||
Infection-related | ||
Site of infection | Urinary | Fluconazole: only agent with urinary concentrations |
Ocular | Triazoles, L-AMB; avoid echinocandins (poor distribution) | |
CNS | Triazoles, L-AMB; avoid echinocandins (poor distribution) | |
Pathogen | ||
Candida species | Disseminated, acute and chronic | Echinocandin, fluconazole, L-AMB |
C krusei | Disseminated, acute and chronic | Echinocandin, L-AMB; avoid fluconazole |
C glabrata | Disseminated, acute and chronic | Echinocandin, L-AMB, voriconazole; avoid fluconazole |
C parapsilosis | Disseminated, acute and chronic | L-AMB, voriconazole; avoid echinocandins |
Trichosporon spp | Disseminated, acute and chronic | Fluconazole, other azoles; amphotericin B not effective |
Aspergillus spp | Sinus, pulmonary, disseminated | Voriconazole, L-AMB, ABLC; no role for fluconazole |
Aspergillus flavus | Sinus, pulmonary, disseminated | Voriconazole; posaconazole alternative |
Fusarium spp | Sinus, pulmonary, cellulitis, disseminated | L-AMB, ABLC; voriconazole maintenance if susceptible |
Scedosporium apiospermum | Sinus, pulmonary, ocular, CNS, bone and soft tissues, disseminated | Voriconazole; posaconazole alternative |
Black molds | Various sites | Voriconazole; posaconazole alternative |
Agents of mucormycosis | Sinus, pulmonary, disseminated | L-AMB, ABLC; posaconazole maintenance if susceptible |
Antifungal agents include triazoles (fluconazole, voriconazole, posaconazole, and itraconazole), echinocandins (anidulafungin, caspofungin, and micafungin), and amphotericin B and its lipid formulations: L-AMB and ABLC. Severe organ dysfunction refers to grade ≥3 according to common toxicity criteria for adverse events (version 3.0). CNS, central nervous system.