What is the treatment for a wound infected with fungus?

Treatment of Fungal Wound Infections

For wound infections with fungus, the recommended treatment is topical or systemic antifungal therapy based on the severity of infection, with fluconazole being the first-line systemic agent for most cases, combined with appropriate wound debridement and care. 1, 2

Assessment and Classification

Before initiating treatment, assess the wound for:

• Depth and extent of infection
• Type of fungus (if known)
• Patient's immune status
• Presence of systemic symptoms

Classification by Severity:

1. Superficial fungal wound infection: Limited to epidermis/dermis
2. Moderate fungal wound infection: Deeper tissue involvement
3. Severe fungal wound infection: Extensive tissue involvement, systemic symptoms, or immunocompromised host

Treatment Algorithm

1. Superficial Fungal Wound Infections

• First-line: Topical antifungal therapy
  • Terbinafine 1% cream applied twice daily for 1-2 weeks 3, 4
  • Clotrimazole 1% cream applied twice daily for 2-4 weeks 1
• Wound care: Thorough mechanical cleansing followed by application of antifungal 1
• Duration: Continue for 1-2 weeks after clinical improvement 2

2. Moderate Fungal Wound Infections

• First-line: Oral fluconazole 400 mg (loading dose) followed by 200-400 mg daily 1, 5
• Alternative: Voriconazole 400 mg (loading dose) followed by 200 mg twice daily 6
• Wound care: Surgical debridement of necrotic tissue plus daily wound inspection 1
• Duration: At least 2-4 weeks, depending on clinical response 1, 2

3. Severe Fungal Wound Infections

• First-line: Systemic voriconazole (loading dose 400 mg twice daily for 2 doses, then 200 mg twice daily) 1, 6
• Alternative: Liposomal amphotericin B 3-5 mg/kg/day IV 1, 2
• Surgical intervention: Aggressive debridement of infected and necrotic tissue 1
• Duration: Minimum 4-6 weeks, continuing until complete resolution of infection 1

Special Considerations

For Candida Species

• For fluconazole-resistant Candida species (e.g., C. glabrata, C. krusei):
  • Switch to an echinocandin or liposomal amphotericin B 1, 2
  • Consider susceptibility testing if no improvement after 3-5 days 2

For Aspergillus Species

• Voriconazole is the treatment of choice 1
• Surgical debridement is strongly recommended in addition to antifungal therapy 1
• For cutaneous aspergillosis, evaluate for disseminated infection 1

For Burns or Massive Soft Tissue Wounds

• Aggressive surgical debridement is essential in addition to systemic antifungal therapy 1
• Consider broader spectrum antifungal coverage initially 1

Wound Care Principles

• Debridement: Remove all necrotic and infected tissue to reduce fungal burden 1
• Dressing: Use dressings that allow daily inspection and maintain a moist wound environment 1
• Off-loading: Reduce pressure on wound areas, especially for foot wounds 1
• Inspection: Monitor wound daily for inpatients, every 2-5 days for outpatients 1

Monitoring Response

• Primary indicators of improvement: Resolution of local and systemic symptoms and clinical signs of inflammation 1
• Continue therapy until complete resolution of infection, not just until wound closure 1, 2
• Consider follow-up cultures to confirm eradication of fungal infection in severe cases

Common Pitfalls to Avoid

1. Inadequate debridement: Failure to remove all infected and necrotic tissue can lead to persistent infection
2. Premature discontinuation: Stopping therapy before complete resolution can lead to recurrence 2
3. Overlooking underlying conditions: Uncontrolled diabetes, immunosuppression, or vascular insufficiency can impair healing
4. Neglecting source control: Drainage of collections and removal of infected foreign bodies are essential 2
5. Delayed treatment: Fungal infections can progress rapidly in immunocompromised patients and require prompt intervention

By following this structured approach based on infection severity, appropriate antifungal selection, and proper wound care, most fungal wound infections can be effectively managed with good outcomes.