From the Guidelines
For pediatric patients with fungal infections, fluconazole is the recommended initial treatment, with a dosage of 6 mg/kg/day on day 1, followed by 3-6 mg/kg/day for a minimum of 14-21 days, due to its efficacy and safety profile 1. When considering treatment options for fungal infections in pediatric patients, it is essential to prioritize the most effective and safest choices.
Treatment Options
- For esophageal disease, fluconazole and itraconazole are effective options, with fluconazole being superior to ketoconazole 1.
- Itraconazole cyclodextrin oral solution is as efficacious as fluconazole for esophageal disease, and can be used as an alternative 1.
- Low-dose intravenous amphotericin B is also effective for refractory disease, with a dosage of 0.3 mg/kg/day for a minimum of 7 days 1.
Considerations
- Voriconazole and caspofungin have limited experience in pediatric patients, and their use is not recommended due to insufficient data 1.
- Good hygiene practices, such as keeping affected areas clean and dry, avoiding sharing personal items, and using separate towels, can help prevent spread and recurrence of fungal infections.
Dosage and Administration
- Fluconazole: 6 mg/kg/day on day 1, followed by 3-6 mg/kg/day for a minimum of 14-21 days 1.
- Itraconazole cyclodextrin oral solution: 2.5 mg/kg/dose twice a day or 5.0 mg/kg/dose once daily for a minimum of 14-21 days 1.
- Amphotericin B: 0.3 mg/kg/day for a minimum of 7 days 1.
From the FDA Drug Label
- 1 Invasive Aspergillosis Voriconazole tablets are indicated in adults and pediatric patients (aged 12 to 14 years weighing greater than or equal to 50 kg and those aged 15 years and older regardless of body weight) for the treatment of invasive apergillosis (IA).
- 2 Candidemia in Non-neutropenic Patients and Other Deep Tissue Candida Infections Voriconazole tablets are indicated in adults and pediatric patients (aged 12 to 14 years weighing greater than or equal to 50 kg and those aged 15 years and older regardless of body weight) for the treatment of candidemia in non-neutropenic patients and the following Candida infections: disseminated infections in skin and infections in abdomen, kidney, bladder wall, and wounds.
- 3 Esophageal Candidiasis Voriconazole tablets are indicated in adults and pediatric patients (aged 12 to 14 years weighing greater than or equal to 50 kg and those aged 15 years and older regardless of body weight) for the treatment of esophageal candidiasis (EC).
- 4 Scedosporiosis and Fusariosis Voriconazole tablets are indicated for the treatment of serious fungal infections caused by Scedosporium apiospermum and Fusarium spp in adults and pediatric patients (aged 12 to 14 years weighing greater than or equal to 50 kg and those aged 15 years and older regardless of body weight) intolerant of, or refractory to, other therapy. Pediatric Use Safety and effectiveness in pediatric patients have not been established through adequate and well-controlled studies for amphotericin B.
The treatment options for fungal infections in pediatric patients are:
- Voriconazole for:
- Invasive aspergillosis
- Candidemia in non-neutropenic patients and other deep tissue Candida infections
- Esophageal candidiasis
- Scedosporiosis and Fusariosis in pediatric patients aged 12 to 14 years weighing greater than or equal to 50 kg and those aged 15 years and older regardless of body weight 2.
- Amphotericin B may be used in pediatric patients, but safety and effectiveness have not been established through adequate and well-controlled studies 3.
From the Research
Treatment Options for Fungal Infections in Pediatric Patients
- The treatment of fungal infections in pediatric patients can involve various antifungal medications, including fluconazole, griseofulvin, itraconazole, and terbinafine 4, 5.
- For invasive fungal diseases, antifungal prophylaxis is often prescribed for high-risk patients, such as those with extreme-low birth weight or hemato-oncologic conditions 6.
- First-line therapy for candidemia in pediatric patients typically consists of either fluconazole or liposomal amphotericin B, while voriconazole is often used as first-line therapy for invasive aspergillosis 6, 7.
- Combination antifungal therapy may be considered for difficult-to-treat infections, although there is limited data to support its use in pediatric patients 8.
- Topical antifungal medications are often effective for superficial fungal infections, such as tinea capitis and tinea corporis, although oral antifungal drugs may be required for more severe cases or in immunosuppressed patients 5.
Antifungal Medications
- Fluconazole has been shown to be effective and safe in the treatment of fungal infections in children, with a similar efficacy and safety profile to that seen in adults 4.
- Griseofulvin is currently the systemic drug of choice for the treatment of tinea capitis in children, although newer antifungal agents such as terbinafine and itraconazole may be considered as alternatives 5.
- Voriconazole and echinocandins have been studied in pediatric patients, although more data are needed to establish their safety and efficacy in this population 7.
Management of Invasive Fungal Disease
- The management of invasive fungal disease in pediatric patients remains a challenge, with varying approaches to diagnosis, treatment, and prevention 6, 7.
- A nationwide survey found that there is significant variability in the use of fungal diagnostic tools, imaging modalities, and antifungal prophylaxis among pediatric centers 6.
- Empirical treatment is often favored in cases of febrile neutropenia, although the choice of antifungal agent may depend on various factors, including the suspected pathogen and the patient's underlying condition 6, 7.