What is the appropriate antifungal treatment for an 8-month-old with a fungal infection?

Antifungal Treatment in an 8-Month-Old

For an 8-month-old with invasive candidiasis, amphotericin B deoxycholate at 1.0 mg/kg/day is the first-line treatment, with fluconazole 12 mg/kg/day as an alternative option. 1

Treatment Selection Based on Clinical Scenario

For Invasive Candidiasis/Candidemia

Primary options:

• Amphotericin B deoxycholate 1.0 mg/kg/day is the preferred agent due to its established safety profile and extensive experience in this age group 1
• Fluconazole 12 mg/kg/day is an effective alternative, particularly for less critically ill infants or those with confirmed susceptible Candida species 1
• Echinocandins (caspofungin) are approved for infants ≥3 months but have limited data in those <3 months; at 8 months, caspofungin can be used at 70 mg/m² loading dose followed by 50 mg/m² daily (not to exceed 70 mg) 1, 2

Species-Specific Considerations

For C. albicans, C. tropicalis, or C. parapsilosis:

• Amphotericin B deoxycholate 0.6-1.0 mg/kg/day OR fluconazole 6-12 mg/kg/day are both appropriate 1

For C. glabrata (less common in infants):

• Amphotericin B deoxycholate 0.7-1.0 mg/kg/day is preferred over fluconazole due to reduced azole susceptibility 1

For C. krusei (rare in this age group):

• Amphotericin B deoxycholate 1.0 mg/kg/day is the treatment of choice, as this species is intrinsically resistant to fluconazole 1

Site-Specific Management

CNS Involvement

• Mandatory lumbar puncture and ophthalmoscopic examination should be performed in all infants with candidemia 1
• If CNS candidiasis is confirmed: Amphotericin B deoxycholate with or without 5-flucytosine (5-FC) 100-150 mg/kg/day divided every 6 hours 1
• Fluconazole 6-12 mg/kg/day can be used for patients unable to tolerate amphotericin B 1
• Remove any intraventricular devices 1

Urinary Tract Involvement

• Imaging of genitourinary tract, liver, and spleen should be performed if sterile body fluid cultures remain persistently positive 1
• For symptomatic cystitis: Fluconazole 3 mg/kg/day for 14 days 1
• For pyelonephritis: Fluconazole 3-6 mg/kg/day for 14 days OR amphotericin B deoxycholate with or without 5-FC 1

Endophthalmitis

• Amphotericin B deoxycholate 0.7-1 mg/kg with 5-FC OR fluconazole OR liposomal amphotericin B 1
• Duration: at least 4-6 weeks, determined by repeated examinations 1
• Surgical intervention may be needed for severe cases 1

Treatment Duration

For candidemia without persistent fungemia or metastatic complications:

• Treat for 3 weeks after the first negative blood culture 1

For disseminated disease with organ involvement:

• Continue until all clinical signs, laboratory abnormalities, and radiologic findings have resolved 1

Critical Pitfalls to Avoid

Lipid formulations of amphotericin B should be used cautiously in infants:

• A large observational study found higher mortality with amphotericin B lipid products compared to amphotericin B deoxycholate (OR 1.96) or fluconazole (OR 2.39) in infants ≤120 days 3
• This may be due to inadequate renal penetration or inappropriate dosing in premature infants 3
• If liposomal amphotericin B is used, ensure urinary tract involvement is excluded 1

Catheter management:

• Remove central venous catheters when feasible, as this improves outcomes 1

Monitoring requirements:

• For 5-flucytosine: Monitor blood levels to minimize toxicity (target peak 40-60 mcg/mL, trough <25 mcg/mL) 1
• For amphotericin B: Monitor renal function and electrolytes, particularly potassium 1

Mucocutaneous Candidiasis

For oropharyngeal candidiasis (thrush):

• Nystatin suspension 200,000-400,000 units PO four times daily for 1-7 days in children 1
• Fluconazole 100-200 mg/day (approximately 3 mg/kg/day for an 8-month-old) is an alternative 1

For esophageal candidiasis:

• Fluconazole 200-400 mg/day (3-6 mg/kg/day) for 14-21 days until clinical improvement 1