Table 4

Practical considerations for individualized selection of antifungal agents for patients with A-Leuk

FactorsSettingAgent 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 
FactorsSettingAgent 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.

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