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.