What is the treatment for white fungus infection?

Treatment of White Fungus Infection

The term "white fungus" is colloquial and typically refers to invasive candidiasis (Candida species infections), which requires treatment based on the specific site and severity of infection, with fluconazole as first-line therapy for most mucocutaneous infections and echinocandins or amphotericin B formulations for invasive disease. 1

Understanding "White Fungus"

The term "white fungus" gained media attention but lacks precise medical definition. In clinical practice, this most commonly refers to:

• Candida species infections (appearing white/cream-colored on culture and clinically) 1
• Less commonly, other fungal pathogens causing invasive disease in immunocompromised patients 2

Treatment Algorithm by Site and Severity

Mucocutaneous Candidiasis

Oropharyngeal Candidiasis:

• First-line: Fluconazole 100-200 mg/day orally for 7-14 days (1-7 days in children) 1, 3
• Alternatives: Nystatin suspension 200,000-400,000 units PO four times daily, or itraconazole 200 mg/day 1
• Clinical resolution typically occurs within several days, but complete the full course to prevent relapse 3

Esophageal Candidiasis:

• First-line: Fluconazole 200-400 mg/day orally for 14-21 days until clinical improvement 1, 3
• Alternatives: Itraconazole 200 mg/day PO, echinocandin, voriconazole, or amphotericin B 0.3-0.7 mg/kg/day IV 1
• Treat for minimum 14 days and at least 7 days following symptom resolution 3, 4

Invasive Candidiasis

Candidemia and Disseminated Disease:

• First-line: Echinocandin (caspofungin, micafungin, or anidulafungin) for critically ill or azole-resistant cases 1
• Alternative: Fluconazole 400-800 mg (6-12 mg/kg) daily for less critically ill patients 1
• Alternative: Amphotericin B deoxycholate 0.7-1 mg/kg/day or liposomal amphotericin B 1
• Continue treatment for at least 14 days following resolution of symptoms AND last positive culture, whichever is longer 1, 4
• Remove all central venous catheters when feasible 1

CNS Candidiasis:

• First-line: Amphotericin B deoxycholate with or without flucytosine (5-FC) 1
• Alternative: Fluconazole 400-800 mg (6-12 mg/kg) daily for patients unable to tolerate amphotericin B 1
• Remove intraventricular devices 1
• Treat until all signs, symptoms, CSF abnormalities, and radiologic findings resolve 1
• Fluconazole or voriconazole can be used as step-down therapy in stable patients 1

Candida Endophthalmitis:

• First-line: Amphotericin B deoxycholate 0.7-1 mg/kg with flucytosine 1
• Alternatives: Fluconazole, liposomal amphotericin B, voriconazole, or echinocandin 1, 5
• Perform diagnostic vitreal aspiration if etiology unknown 1
• Surgical intervention required for severe endophthalmitis or vitreitis 1
• Minimum treatment duration: 4-6 weeks, determined by repeated examinations 1

Urinary Tract Infections:

• Asymptomatic cystitis: Usually no therapy needed; eliminate predisposing factors 1
• Symptomatic cystitis: Fluconazole 200 mg (3 mg/kg) daily for 14 days 1
• Pyelonephritis: Fluconazole 200-400 mg (3-6 mg/kg) daily for 14 days 1
• For pyelonephritis with suspected dissemination: treat as candidemia 1

Chronic Disseminated Candidiasis:

• First-line: Fluconazole, liposomal amphotericin B, or echinocandin 1
• Continue treatment until lesions resolve (typically 3-6 months) 1
• Fluconazole or voriconazole can be used as step-down therapy in stable patients 1

Special Populations

Neonatal Candidiasis:

• First-line: Amphotericin B deoxycholate 1.0 mg/kg/day, fluconazole 12 mg/kg/day, or echinocandin 1
• Perform lumbar puncture and ophthalmoscopic examination in all neonates with positive cultures 1
• Image genitourinary tract, liver, and spleen if persistently positive cultures 1
• Treat for 3 weeks for candidemia without persistent fungemia or metastatic complications 1

Critical Pitfalls to Avoid

• Never treat Candida isolated from lower respiratory tract without histopathologic confirmation - colonization is common and does not require therapy 1
• Do not use fluconazole empirically if mucormycosis (zygomycosis) is suspected - amphotericin B formulations are mandatory 1, 5
• Always remove infected catheters and devices when treating candidemia or device-related infections 1
• Monitor for hepatotoxicity - asymptomatic transaminase elevations occur in 1-13% of patients on azoles, with rare fatal hepatitis 6
• Assess for drug interactions - fluconazole and voriconazole inhibit cytochrome P-450 enzymes 6, 5
• Ensure adequate treatment duration - premature discontinuation leads to relapse 1, 3

Monitoring and Follow-up

• Continue therapy until clinical parameters and laboratory tests indicate active infection has subsided 3
• For AIDS patients with cryptococcal or recurrent oropharyngeal candidiasis, maintenance therapy prevents relapse 1, 3
• Reversal of immunosuppression when feasible improves outcomes 1
• Obtain fungal cultures and susceptibility testing before initiating therapy when possible 1, 4