BNF for Children 2011-2012

308 5.2.5 Other antifungals BNFC 2011–20125 InfectionsMycamine c (Astellas) TAIntravenous infusion, powder for reconstitution,micafungin (as sodium), net price 50-mg vial =£196.08; 100-mg vial = £341.005.2.5 Other antifungalsFlucytosine is used with amphotericin in a synergisticcombination. Bone marrow depression can occur whichlimits its use, particularly in children with AIDS; weeklyblood counts are necessary during prolonged therapy.Resistance to flucytosine can develop during therapyand sensitivity testing is essential before and duringtreatment. For the role of flucytosine in the treatmentof systemic candidiasis and cryptococcal meningitis, seep. 300.Griseofulvin is effective for widespread or intractabledermatophyte infections but has been superseded bynewer antifungals, particularly for nail infections.Griseofulvin is used in the treatment of tinea capitis. Itis the drug of choice for trichophyton infections inchildren, see p. 301. Duration of therapy is dependenton the site of the infection and may extend to a numberof months.Terbinafine is the drug of choice for fungal nail infectionsand is also used for ringworm infections whereoral treatment is considered appropriate (see p. 301.FLUCYTOSINECautions blood disorders; liver- and kidney-functiontests and blood counts required (weekly in blooddisorders); interactions: Appendix 1 (flucytosine)Renal impairment liver- and kidney-function testsand blood counts required weekly; use normal doseevery 12 hours if creatinine clearance 20–40 mL/minute; use normal dose every 24 hours if creatinineclearance 10–20 mL/minute; use initial normal dose ifcreatinine clearance less than 10 mL/minute and thenadjust dose according to plasma-flucytosine concentrationPregnancy teratogenic in animal studies; manufactureradvises use only if potential benefit outweighsriskBreast-feeding manufacturer advises avoidSide-effects nausea, vomiting, diarrhoea, rashes; lessfrequently cardiotoxicity, confusion, hallucinations,convulsions, headache, sedation, vertigo, alterationsin liver function tests (hepatitis and hepatic necrosisreported), and toxic epidermal necrolysis; blood disordersincluding thrombocytopenia, leucopenia, andaplastic anaemia reportedPharmacokinetics for plasma-concentration monitoringblood should be taken shortly before startingthe next infusion. Plasma concentration for optimumresponse 25–50 mg/litre (200–400 micromol/litre)—should not be allowed to exceed 80 mg/litre(620 micromol/litre)Licensed use tablets not licensedIndication and doseSystemic yeast and fungal infections, adjunctto amphotericin in severe systemic candidiasisand in other severe or long-standing infections. By intravenous infusion or by mouthNeonate 50 mg/kg every 12 hoursChild 1 month–18 years 50 mg/kg every 6 hours;extremely sensitive organisms, 25–37.5 mg/kgevery 6 hours may be sufficient; treatment continuedusually for not more than 7 daysCryptococcal meningitis (adjunct to amphotericin,see Cryptococcosis, p. 301). By intravenous infusion or by mouthNeonate 50 mg/kg every 12 hoursChild 1 month–18 years 25 mg/kg every 6 hoursfor 2 weeksAdministration for intravenous infusion, give over20–40 minutesAncotil c (Meda) AIntravenous infusion, flucytosine 10 mg/mL. Netprice 250-mL infusion bottle = £30.33 (hosp. only)Electrolytes Na + 34.5 mmol/250-mL bottleNote Flucytosine tablets may be available from ‘special-order’manufacturers or specialist importing companies, see p. 809Extemporaneous formulations available seeExtemporaneous Preparations, p. 6GRISEOFULVINCautions interactions: Appendix 1 (griseofulvin)Skilled tasks May impair performance of skilled tasks;effects of alcohol enhancedContra-indications systemic lupus erythematosus(risk of exacerbation); acute porphyria (section 9.8.2)Hepatic impairment avoid in severe liver diseasePregnancy avoid (fetotoxicity and teratogenicity inanimals); effective contraception required during andfor at least 1 month after administration to women(important: effectiveness of oral contraceptives maybe reduced, additional contraceptive precautions e.g.barrier method, required); also males should avoidfathering a child during and for at least 6 months aftertreatmentBreast-feeding avoid—no information availableSide-effects nausea, vomiting, diarrhoea, headache;also reported, abdominal pain, dyspepsia, hepatotoxicity,glossitis, taste disturbances, sleep disturbances,dizziness, fatigue, confusion, agitation,depression, impaired co-ordination and hearing, peripheralneuropathy, menstrual disturbances, renalfailure, leucopenia, systemic lupus erythematosus,rash (including rarely erythema multiforme, toxicepidermal necrolysis), and photosensitivityLicensed use tablets licensed for use in children (agerange not specified by manufacturer); suspensionnot licensedIndication and doseDermatophyte infections where topical therapyhas failed or is inappropriate. By mouthChild 1 month–12 years 10 mg/kg (max. 500 mg)once daily or in divided doses; in severe infectiondose may be doubled, reducing when responseoccursChild 12–18 years 500 mg once daily or individed doses; in severe infection dose may bedoubled, reducing when response occurs