Antimicrobial Use Guidelines (AMUG) version 21 - UW Health

Appendix E: UWHC Guidelines for the Appropriate Use of Antifungal DrugsGuidelines developed by UWHC Antimicrobial Use Subcommittee and the Drug Policy Program(DPP)Authors: Barry Fox, MD; Dennis Maki, MD; David Andes, MDCoordination: Sara Shull, PharmD, MBA, Manager Drug Policy ProgramReviewed by: David Andes, MD; Barry Fox MD; Dennis Maki, MD; Carol Spiegel, PhD; AndrewUrban, MD; Brad Kahl, MD; Walter Longo, MD; Mark Juckett. MD; Natalie Callander, MDApproved By P&T Committee: September 2003Last Reviewed: February 2007Next Scheduled Review Date: June 2011A. Management of Patients with Documented or Probable Invasive Fungal Infections1.0 Candida Infections1.1 There are no data to indicate that lipid-associated IV amphotericin B issuperior therapeutically to conventional amphotericin B in adequatedoses (0.3-0.6 mg/kg/day).1.2 For Candida bloodstream infections, echinocandins may be marginallysuperior to conventional IV amphotericin B. 1,2,3 Three to ten days ofechinocandin therapy with stepdown to oral fluconazole may beconsidered as one standard of care.1.3 For C. albicans infections, IV fluconazole (400 – 800 mg/day) generallygives results therapeutically comparable to conventional IV amphotericinB (and presumably echinocandin). 4,51.4 For non-albicans Candida infections, fluconazole may fail because ofreduced susceptibility. 6 Susceptibility testing for Candida glabrataisolated from sterile body sites is automatically sent for susceptibilitytesting. Other testing is available upon request. An echinocandin or IVamphotericin B may be preferred. 7,81.5 Voriconazole has recently been approved for the treatment ofcandidemia, but clinical experience is limited; published data available atthe time of approval of this document are limited to salvage therapy. 92.0 Deep Aspergillus Infections2.1 There are no data that conclusively show the lipid-associatedamphotericin preparations are therapeutically superior to conventional IVamphotericin B in full doses (≥ 1 mg/kg/day). 10 However, since it isessential to use full dose IV amphotericin B for filamentous fungalinfections (>1 mg/kg/d), a dosage which produces substantialnephrotoxicity, in general, lipid-associated preparations of amphotericinB (5 mg/kg/day) are preferable for documented filamentous fungalinfection, especially deep Aspergillus or Zygomycetes infections.2.2 Voriconazole appears to be superior to all IV amphotericin B products forinvasive Aspergillus infections and is recommended for initial therapy ofprobable or documented invasive Aspergillus infections. 11 Echinocandinshave also been shown to be effective for invasive aspergillosis inpatients refractory to or intolerant of conventional antifungal therapy. 12