Antifungal agents

✓ Azole antifungal

1.

Generic name : VORICONAZOLE

Brand name : Vfend

Classification : Azole antifungal

Dosage/frequency and Route

Aspergillosis

Adult/Geriatric: IV 6 mg/kg q12h day 1, then 4 mg/kg q12h. May reduce to 3 mg/kg q12h if not tolerated
PO >40 kg, 400 mg q12h day 1, then 200 mg q12h. May increase to 300 mg q12h if inadequate response.
<40 kg, 400 mg q12h day 1, then 100 mg q12h. May increase to 150 mg q12h if inadequate response.

Esophageal Candidiasis

Adult/Geriatric: PO >40 kg, 200 mg q12h for a minimum of 14 d and for at least 7 d after resolution of
symptoms; <40 kg, 100 mg q12h for a minimum of 14 d and for at least 7 d after resolution of
symptoms.

Dose Adjustment for Concomitant Fosphenytoin or Phenytoin

Adult/Geriatric: IV 6 mg/kg q12h day 1, then 5 mg/kg q12h. PO >40 kg, 400 mg q12h day 1, then 400 mg
q12h. <40 kg, 400 mg q12h day 1, then 200 mg q12h

Mechanism of action

Inhibits fungal cytochrome P-450 enzymes used for an essential step in fungal ergosterol biosynthesis.
The subsequent loss of ergosterol in the fungal cell wall may be responsible for the antifungal activity of
voriconazole.

Indication

 Aspergillosis
 Esophageal Candidiasis
 candidemia in nonneutropenic

Contraindication
Known hypersensitivity to voriconazole; intravenous voriconazole should be avoided in moderate or
severe renal impairment (Clcr <50 mL/min); severe hepatic impairment; children <2 y; history of
galactose intolerance; Lapp lactase deficiency or glucose-galactose malabsorption; concurrent use of
sirolimus; coadministration of the CYP3A4 substrates pimozide or quinidine; concurrent use of rifampin,
rifabutin, carbamazepine and long-acting barbiturates, ergot alkaloids; sunlight (UV) exposure;
pregnancy (category D); lactation.

Side effects

 abnormal vision.
 difficulty seeing colors.
 diarrhea.
 nausea.
 vomiting.
 headache.
 dizziness.
 dry mouth.

Adverse effects

 Body as a Whole: Peripheral edema, fever, chills.

 CNS: Headache, hallucinations, dizziness.
 CV: Tachycardia, hypotension, hypertension, vasodilation.
 GI: Nausea, vomiting, abdominal pain, abnormal LFTs, diarrhea, cholestatic jaundice, dry mouth.
 Metabolic: Increased alkaline phosphatase, AST, ALT, hypokalemia, hypomagnesemia.
 Skin: Rash, pruritus.
 Special Senses: Abnormal vision (enhanced brightness, blurred vision, or color vision changes),
photophobia.

Nursing Responsibility

 Monitor visual acuity, visual field, and color perception if treatment continues beyond 28 d.
 Withhold drug and notify physician if skin rash develops.
 Monitor cardiovascular status especially with preexisting CV disease.
 Lab tests: Monitor baseline and periodic LFTs including bilirubin; patients who develop abnormal
liver function tests during therapy should be
 monitored for the development of more severe hepatic injury. Monitor frequently renal
function tests, especially serum creatinine.
 Monitor periodic CBC with platelet count, Hct & Hgb, serum electrolytes, alkaline phosphatase,
blood glucose, and lipid profile.
 Concurrent drugs: Monitor PT/INR closely with warfarin as dose adjustments of warfarin may be
needed.
  Monitor frequently blood glucose levels with sulfonylurea drugs as reduction in the sulfonylurea
dosage may be needed.
 Monitor for and report any of the following: S&S of rhabdomyolysis in patient receiving a statin
drug; prolonged sedation in patient receiving a benzodiazepine; S&S of heart block, bradycardia,
or CHF in patient receiving a calcium channel blocker

2.

Generic name

FLUCONAZOLE

Brand name

Diflucan

Classification

Azole antifungal

Dosage/frequency and Route

Oropharyngeal Candidiasis

Adult: PO/IV 200 mg day 1, then 100 mg q.d. x 2 wk

Child: PO/IV 3–6 mg/kg/d

Esophageal Candidiasis

Adult: PO/IV 200 mg day 1, then 100 mg q.d. x 3 wk

Child: PO/IV 3–6 mg/kg/d

Systemic Candidiasis

Adult: PO/IV 400 mg day 1, then 200 mg q.d. x 4 wk

Child: PO/IV 3–6 mg/kg/d

Vaginal Candidiasis

Adult: PO 150 mg x 1 dose

Cryptococcal Meningitis

Adult: PO/IV 400 mg day 1, then 200 mg q.d. x 10–12 wk

Child: PO/IV 3–6 mg/kg/d

Mechanism of action

Fungistatic; may also be fungicidal depending on concentration. Interferes with formation of ergosterol,
the principal sterol in the fungal cell membrane that, when depleted, interrupts membrane function.

Indication

 Oropharyngeal Candidiasis
 Esophageal Candidiasis
 Systemic Candidiasis
 Vaginal Candidiasis

Contraindication

Hypersensitivity to fluconazole or other azole antifungals; pregnancy (category C), lactation.

Side effects

 Nausea
 Vomiting
 Diarrhea,
 stomach upset/pain
 headache
 dizziness
 hair loss may occur.

Adverse effects

CNS: Headache

GI: Nausea, vomiting, abdominal pain, diarrhea, increase in AST in patients with cryptococcal meningitis
and AIDS.

Skin: Rash

Nursing Responsibility
  Monitor for allergic response. Patients allergic to other azole antifungals may be allergic to
fluconazole.
 Lab tests: Monitor BUN, serum creatinine, and liver function.
 Note: Drug may cause elevations of the following laboratory serum values: ALT, AST, alkaline
phosphatase, bilirubin.
 Monitor for S&S of hepatotoxicity.
 Monitor carefully for loss of glycemic control if diabetic.

3.

Generic name

KETOCONAZOLE

Brand name

Nizoral

Classification

Azole antifungal

Dosage/frequency and Route

Fungal Infections

Adult: PO 200–400 mg once/d Topical Apply 1–2 times/d to affected area and surrounding skin

Child: PO >2 y, 3.3–6.6 mg/kg/d as single dose

Dandruff

Adult/Child: Topical Shampoo twice a week for 4 wk with at least 3 d between shampoos

Mechanism of action

Fungistatic; may also be fungicidal depending on concentration. Interferes with formation of ergosterol,
the principal sterol in the fungal cell membrane that, when depleted, interrupts membrane function.

Indication

 Fungal Infection
 Dandruff
Contraindication

Hypersensitivity to ketoconazole or any component in the formulation; chronic alcoholism, fungal

meningitis; onychomycosis; ocular exposure, ophthalmic administration. Safety during pregnancy
(category C), lactation, or in children <2 y is not established.

Side effects

 nausea.
 headache.
 diarrhea.
 stomach pain.
 abnormal liver function test results.

Adverse effects

Oral—Body as a Whole: Skin rash, erythema, urticaria, pruritus, angioedema, anaphylaxis.

GI: Nausea, vomiting, anorexia, epigastric or abdominal pain, constipation, diarrhea, transient elevation
in serum liver enzymes, fatal hepatic necrosis (rare).

Hematologic: With high doses, lowers serum testosterone and ACTH-induced corticosteroid serum
levels, transient decreases in serum cholesterol and triglycerides; hyponatremia (rare). Urogenital:
Gynecomastia (males), breast pain; uterine bleeding, loss of libido, impotence, oligospermia, hair loss.

Other: Acute hypoadrenalism (reduction of adrenal stress syndrome), renal hypofunction.

Topical—Skin: Mild transient erythema, severe irritation, pruritus, stinging.

Nursing Responsibility

 Lab tests: Monitor baseline liver function tests (AST, ALT, alkaline phosphatase, and bilirubin)
and repeat at least monthly throughout therapy.
 Monitor for S&S of hepatotoxicity (see Appendix F). Discontinue drug immediately to prevent
irreversible liver damage and report to physician.
 Note: Drowsiness and dizziness are early and time-limited adverse effects.
 Inform the patient to Do not drive or engage in potentially hazardous activities until response to
drug is known
 Inform the patient to Do not alter dose or dose interval and do not stop taking ketoconazole
before consulting the physician.
 Inform the patient to avoid Breastfeeding while taking the drug
✓Echinocandin Antifungal

1.

Generic name

CASPOFUNGIN

Brand name

Cancidas

Classification

Echinocandin Antifungal

Dosage/frequency and Route

Invasive Aspergillosis, Empirical Therapy, Candida

Adult: IV Loading Dose: 70 mg day 1 IV Maintenance Dose: 50 mg qd thereafter

Mechanism of action

Caspofungin is an antifungal agent that inhibits the synthesis of an integral component of the fungal cell
wall of susceptible Aspergillus species and Candida species.

Indication

Invasive Aspergillosis, Empirical Therapy, Candida

Contraindication

Hypersensitivity to any component of this product; pregnancy (category C); not studied in patients with
ESRF, or children

Side effects

 diarrhea,
 fever,
 flushing (warmth, redness, or tingly feeling of the skin),
 headache,
 irritation at the injection site,
 skin rash or itching,
  dizziness, or
 lightheadedness
 Nausea
 Vomiting

Adverse effects

 Body as a Whole: Anaphylaxis, chills, injection site reaction, sensation of warmth.

 CNS: Headache
 CV: Sinus tachycardia
 GI: Nausea, vomiting, diarrhea, abdominal pain.
 Hematologic/Lymphatic: Phlebitis, thrombophlebitis, vasculitis, anemia
 Hepatic: Elevated liver enzymes.
 Metabolic: Anorexia, hypokalemia
 Musculoskeletal: Pain, myalgia.
 Respiratory: Acute respiratory distress syndrome, dyspnea. Skin: Rash, facial swelling, pruritus.

Nursing Responsibility

 Monitor for S&S of hypersensitivity during IV infusion; frequently monitor IV site for
thrombophlebitis.
 Monitor for and report S&S of fluid retention (e.g., weight gain, swelling, peripheral edema),
especially with known cardiovascular disease.
 Lab tests: Baseline and periodic LFTs; periodic kidney function tests, serum electrolytes, and CBC
with differential, platelet count.
 Monitor blood levels of tacrolimus with concurrent therapy.
 Inform the patient to do not breast feed while taking the drugs (for lactating mother only)

2.

Generic name

MICAFUNGIN

Brand name

Mycamine

Classification

Echinocandin Antifungal

Dosage/frequency and Route

Esophageal Candidiasis
Adult: IV 150 mg/d over 1 h

Candidiasis Prophylaxis in Patients Undergoing Hematopoietic Stem Cell Transplantation

Adult: IV 50 mg/d over 1 h

Mechanism of action

Micafungin is an antifungal agent that inhibits the synthesis of glucan, an essential component of fungal
cell walls.

Indication

 Esophageal Candidiasis
 Candidiasis Prophylaxis in Patients Undergoing Hematopoietic Stem Cell Transplantation

Contraindication

Hypersensitivity to any component in micafungin. Safety and efficacy in children are unknown.

Side effects

 nausea,
 vomiting,
 stomach pain,
 indigestion,
 diarrhea,
 constipation,
 headache,
 trouble sleeping (insomnia),
 flushing (warmth, redness, or tingly feeling),
 itching or skin rash, or
 injection site reactions (pain, swelling, or tenderness).

Adverse effects

CNS: Headache, dizziness, somnolence

CV: Flushing, hypertension, phlebitis.

GI: Nausea, vomiting, diarrhea, abdominal pain.

Hematologic/Lymphatic: Anemia, hemolytic anemia, leukemia, neutropenia, thrombocytopenia.

Hepatic: Elevated liver enzymes, jaundice.

Metabolic: Hypocalcemia, hypokalemia, hypomagnesemia.

Skin: Pruritis, rash

. Body as a Whole: Injection site pain, pyrexia, rigors.

Nursing Responsibility

 Monitor for S&S of hypersensitivity during IV infusion; frequently monitor IV site for
thrombophlebitis.
 Monitor for S&S of hemolytic anemia (i.e., jaundice).
 Lab tests: Periodic LFTs, kidney function tests, serum electrolytes, and CBC.
 Monitor blood levels of sirolimus or nifedipine with concurrent therapy. If sirolimus or
nifedipine toxicity occurs, dosages of these drugs should be reduced.

3.

Generic name

Anidulafungin

Brand name

Eraxis

Classification

Echinocandin Antifungals

Dosage/frequency and Route

Intravenous

Oesophageal candidiasis

Adult: Loading dose of 100 mg on day 1, then 50 mg once daily thereafter. Continue treatment for at
least 14 days and for at least 7 days following resolution of symptoms. To be given by IV infusion. Max
infusion rate: 1.1 mg/min.

Elderly: No dosage adjustment needed.

Intravenous

Invasive candidiasis, Candidaemia, Candida infections (intra-abdominal abscess, pertonitis)

Adult: Loading dose of 200 mg on day 1, then 100 mg once daily thereafter. Continue treatment for at
least 14 days after the last positive culture. To be given by IV infusion. Max infusion rate: 1.1 mg/min.

Elderly: No dosage adjustment needed.

Reconstitution

Reconstitute each 50 mg vial w/ sterile water for inj 15 mL, or each 100 mg vial w/ sterile water for inj
30 mL to provide a concentration of 3.33 mg/mL. Further dilute the reconstituted solution w/ either
dextrose inj 5% or sodium chloride inj 0.9% to obtai

Mechanism of action

Anidulafungin is a semi-synthetic echinocandin with antifungal activity. Anidulafungin inhibits glucan

synthase, an enzyme present in fungal, but not mammalian cells. This results in inhibition of the
formation of 1,3-β-D-glucan, an essential component of the fungal cell wall.

Indication

 Candidemia
 Esophageal Candidiasis
 Candida Aurusis

Contraindication

 Patients with known hypersensitivity to anidulafungin, any component of ERAXIS, or other

echinocandins
 Patients with known or suspected Hereditary Fructose Intolerance

Side effects

 flushing or hot flashes,

 dizziness,
 diarrhea,
 constipation,
 headache,
 nausea,
 vomiting, or.
 injection site reactions (pain, swelling, or irritation).

Adverse effects

 Infusion-related reactions (e.g. pruritus, urticaria, rash, hypotension, dyspnoea, flushing)

  nausea
 diarrhoea
 phlebitis/thrombophlebitis
 neutropaenia
 hypokalaemia
 headache
 elevated alkaline phosphatase
 hepatic enzymes
 γ-glutamyltransferase.

Nursing Responsibility

 Advise pregnant women and females of reproductive potential of the potential risk of ERAXIS to
a fetus.
 Observe for anaphylactic reactions, including shock if these reactions occur, ERAXIS may be
discontinued and appropriate treatment administered.
 Inform patients about the risk of developing abnormal liver function tests and/or hepatic
dysfunction.
 Monitor liver function test

✓Azole Topical Antifungals

1.

Generic name

BUTOCONAZOLE NITRATE

Brand name

Femstat-One

Classification

Azole Topical Antifungals

Dosage/frequency and Route

Vulvovaginal Candidiasis
Adult: Topical 1 applicator full intravaginally h.s. for 3 d, may be extended another 3 d if needed

Pregnant women: Topical 1 applicator full intravaginally h.s. for 6 d

Mechanism of action

Imidazole derivative with antifungal activity. Alters fungal cell membrane permeability, permitting loss
of phosphorous compounds, potassium, and other essential intracellular constituents with consequent
loss of ability to replicate. Action takes place primarily on medicated infected surface tissues.

Indication

Local treatment of vulvovaginal candidiasis.

Contraindication

First trimester of pregnancy (category C). Safety during lactation or in children is not established.

Side effects

 pelvic pain or cramps

 vaginal burning or itching
 vaginal pain and swelling
 mild vaginal irritation after use

Adverse effects

 Urogenital: Vulvar or vaginal burning, vulvar itching, discharge, soreness, swelling; urinary
frequency and burning.
 Skin: Itching of fingers.
 CNS: Headache.

Nursing Responsibility

 Monitor for therapeutic effectiveness. Candidiasis in nonpregnant women is usually controlled

in 3 d.
 Inform the patient that the Patient's sexual partner should wear a condom during intercourse.
 Inform the patient to not breast feed while taking this drug without consulting physician.

2.

Generic name

OXICONAZOLE NITRATE

Brand name

Oxistat
Classification

Azole Topical Antifungals

Dosage/frequency and Route

Tinea and Other Dermal Infections

Adult: Topical Apply to affected area once daily in the evening

Mechanism of action

Synthetic antifungal agent that presumably works by altering cellular membrane of the fungi, resulting
in increased membrane permeability, secondary metabolic effects, and growth inhibition.

Indication

Tinea and Other Dermal infections

Contraindication

Hypersensitivity to oxiconazole.

Side effects

Adverse effects

 Skin: Transient burning and stinging, dryness, erythema, pruritus, and local irritation

Nursing Responsibility

 Inform the patient to Use only externally. Do not use intravaginally.

3.

Generic name

KETOCONAZOLE

Brand name

Nizoral
Classification

Topical Azole antifungal

Dosage/frequency and Route

Fungal Infections

Adult: PO 200–400 mg once/d Topical Apply 1–2 times/d to affected area and surrounding skin

Child: PO >2 y, 3.3–6.6 mg/kg/d as single dose

Dandruff

Adult/Child: Topical Shampoo twice a week for 4 wk with at least 3 d between shampoos

Mechanism of action

Fungistatic; may also be fungicidal depending on concentration. Interferes with formation of ergosterol,
the principal sterol in the fungal cell membrane that, when depleted, interrupts membrane function

Indication

 Fungal Infection
 Dandruff

Contraindication

Hypersensitivity to ketoconazole or any component in the formulation; chronic alcoholism, fungal

meningitis; onychomycosis; ocular exposure, ophthalmic administration. Safety during pregnancy
(category C), lactation, or in children <2 y is not established.

Side effects

 nausea.
 headache.
 diarrhea.
 stomach pain.
 abnormal liver function test results.

Adverse effects

 Oral—Body as a Whole: Skin rash, erythema, urticaria, pruritus, angioedema, anaphylaxis.

  GI: Nausea, vomiting, anorexia, epigastric or abdominal pain, constipation, diarrhea, transient
elevation in serum liver enzymes, fatal hepatic necrosis (rare).
 Hematologic: With high doses, lowers serum testosterone and ACTH-induced corticosteroid
serum levels, transient decreases in serum cholesterol and triglycerides; hyponatremia (rare).
 Urogenital: Gynecomastia (males), breast pain; uterine bleeding, loss of libido, impotence,
oligospermia, hair loss. Other: Acute hypoadrenalism (reduction of adrenal stress syndrome),
renal hypofunction.
 Topical—Skin: Mild transient erythema, severe irritation, pruritus, stinging.

Nursing Responsibility

 Lab tests: Monitor baseline liver function tests (AST, ALT, alkaline phosphatase, and bilirubin)
and repeat at least monthly throughout therapy.
 Monitor for S&S of hepatotoxicity (see Appendix F). Discontinue drug immediately to prevent
irreversible liver damage and report to physician
 Inform to avoid engaging in potentially hazardous activities until response to drug is known.
 Inform patient to Avoid OTC drugs for gastric distress, such as Rolaids, Tums, Alka-Seltzer and
check with physician before taking any other nonprescribed medicines.
 Inform patient do not alter dose or dose interval and do not stop taking ketoconazole before
consulting the physician.

✓ Polyenes Antifungals

1.

Generic name

NYSTATIN

Brand name

Mycostatin

Classification

Polyenes Antifungals

Dosage/frequency and Route

Candida Infections

Adult: PO 500,000–1,000,000 U t.i.d.; 1–4 troches 4–5 times/d; Suspension: 400,000–600,000 U q.i.d.
Intravaginal 1–2 tablets daily for 2 wk

Child: PO Suspension: 400,000–600,000 U q.i.d.

Infant: PO 100,000–200,000 U q.i.d

Mechanism of action

Nontoxic, nonsensitizing antifungal antibiotic produced by Streptomyces noursei. Binds to sterols in

fungal cell membrane, thereby changing membrane potential and allowing leakage of intracellular
components.

Indication

Candida Infection

Contraindication

Use of vaginal tablets during pregnancy (category C); vaginal infections caused by Gardnerella vaginalis
or Trichomonas sp.

Side effects

 Mouth irritation
 diarrhea
 Nausea
 Vomiting
 stomach upset

Adverse effects

GI: Nausea, vomiting, epigastric distress, diarrhea (especially with high oral doses).

Nursing Responsibility

 Monitor oral cavity, especially the tongue, for signs of improvement.

 Avoid occlusive dressings or applications of ointment preparation to moist, dark areas of
body because they favor growth of yeast
 This drug may cause contact dermatitis. Stop using the drug if redness and swelling .or
irritation develops.
 Take for oral candidiasis (thrush) treatment after meals and at bedtime.
 Dissolve troche in mouth (about 30 min). Do not chew or swallow. Avoid food and drink
during period of dissolving and for 30 min after treatment.
 Continue medication for vulvovaginal candidiasis during menstruation.
 Use vaginal tablets up to 6 wk before term to prevent thrush in the newborn
 Avoid Breast-feeding while taking the drug

2.

Generic name
AMPHOTERICIN B

Brand name

Fungizone

Classification

Polyene Antifungal

Dosage/frequency and Route

Systemic Infections
 Adult: IV Test Dose 1 mg dissolved in 20 mL of D5W by slow infusion (over 10–30 min) IV
Maintenance Dose 0.25–0.3 mg/kg/day infused over 4–6 h, may gradually increase by 0.5–0.75
mg/kg/d up to 1–1.5 mg/kg/d
 Child: IV Test Dose 0.1 mg/kg up to 1 mg dissolved in 20 mL of D5W by slow infusion (over 10–
30 min) IV Maintenance Dose 0.4 mg/kg/d infused over 4–6 h, may increase by 0.25 mg/kg/d to
target dose of 0.25–1 mg/kg/d infused over 2–6 h
Candiduria
 Adult: Irrigation 5–50 mg/1000 mL sterile water instilled continuously into the bladder via a 3-
way closed drainage catheter system at a rate of 1000 mL/24 h
Oral Candidiasis
 Adult/Child: PO 100 mg swish & swallow q.i.d.

Cutaneous Candidiasis

 Adult/Child/Infant: Topical apply to lesions 2–4 times/d for 1–4 wks

Mechanism of action

Fungistatic antibiotic produced by Streptomyces nodosus. Fungicidal at higher concentrations,

depending on sensitivity of fungus.

Indication

Contraindication

Hypersensitivity to amphotericin.

Side effects

 nausea, vomiting, stomach pain, diarrhea;

 upset stomach, loss of appetite;
 muscle or joint pain;
 headache, ringing in your ears;
 pain, bruising, or swelling where the medicine was injected;
  weight loss; or.
 flushing (warmth, redness, or tingly feeling).

Adverse effects

 Body as a Whole: Hypersensitivity (pruritus, urticaria, skin rashes, fever, dyspnea, anaphylaxis);
fever, chills.
 CNS: Headache, sedation, muscle pain, arthralgia, weakness.
 CV: Hypotension, cardiac arrest
 Special Senses: Ototoxicity with tinnitus, vertigo, loss of hearing.
 GI: nausea, vomiting, diarrhea, epigastric cramps, anorexia, weight loss. Hematologic: Anemia,
thrombocytopenia.
 Metabolic: Hypokalemia, hypomagnesemia. Urogenital: Nephrotoxicity, urine with low specific
gravity.
 Skin: Dry, erythema, pruritus, burning sensation; allergic contact dermatitis, exacerbation of
lesions.
 Other: Pain; arthralgias, thrombophlebitis (IV site), superinfections.

Nursing Responsibility

 Lab tests: Baseline C&S tests prior to initiation of therapy; start drug pending results. Baseline
and periodic BUN, serum creatinine, creatinine clearance; during therapy periodic CBC, serum
electrolytes (especially K+, Mg++, Na+, Ca++), and liver function tests.
 Monitor for S&S of local inflammatory reaction or thrombosis at injection site, particularly if
extravasation occurs.
 Monitor cardiovascular and respiratory status and observe patient closely for adverse effects
during initial IV therapy. If a test dose (1 mg over 20–30 min) is given, monitor vital signs every
30 min for at least 4 h. Febrile reactions (fever, chills, headache, nausea) occur in 20–90% of
patients, usually 1–2 h after beginning infusion, and subside within 4 h after drug is
discontinued. The severity of this reaction usually decreases with continued therapy. Keep
physician informed.
 Monitor I&O and weight. Report immediately oliguria, any change in I&O ratio and pattern, or
appearance of urine [e.g., sediment, pink or cloudy urine (hematuria)], abnormal renal function
tests, unusual weight gain or loss. Generally, renal damage is reversible if drug is discontinued
when first signs of renal dysfunction appear.
 Report to physician and withhold drug, if BUN exceeds 40 mg/dL or serum creatinine rises above
3 mg/dL. Dosage should be reduced or drug discontinued until renal function improves.
 Consult physician about the appearance of mild erythema surrounding topical application to
skin lesions. This may be an indication to reduce frequency of topical application.
 Consult physician for guidelines on adequate hydration and adjustment of daily dose as a
possible means of avoiding or minimizing nephrotoxicity.
  Report promptly any evidence of hearing loss or complaints of tinnitus, vertigo, or unsteady gait.
Tinnitus may not be a complaint in older adults or the very young. Other signs of ototoxicity (i.e.,
vertigo or hearing loss) are more reliable indicators of ototoxicity in these age groups.

Generic name

NATAMYCIN

Brand name

Natacyn

.Classification

Polyenes Antifungal

Dosage/frequency and Route

Fungal Keratitis

Adult: Ophthalmic 1 drop in conjunctival sac of infected eye q1–2h for 3–4 d, then decrease to 1 drop
q6–8h, then gradually decrease to 1 drop q4–7d

Mechanism of action

Mechanism of action simulates that of amphotericin B and nystatin by binding to sterols in the fungal
cell membrane.

Indication

Fungal keratitis

Contraindication

Concomitant administration of a corticosteroid

Side effects

 mild eye irritation or discomfort (redness stinging or burning)

 allergic reaction.
 change in vision.
 chest pain.
 corneal opacity.
 shortness of breath.
  eye swelling.
 eye pain

Adverse effects

Special Senses: Blurred vision, photophobia, eye pain. Uneven adherence of suspension to epithelial
ulcerations or in fornices

Nursing Responsibility

 Inspect eye for response and tolerance at least twice weekly.

 Note: Lack of improvement in keratitis within 7–10 d suggests that causative organisms may not
be susceptible to natamycin. Reevaluation is indicated and possibly a change in therapy
 Inform the patient to Expect temporary light sensitivity. Be prepared to wear sunglasses
outdoors after drug administration and perhaps for a few hours indoors.
 Inform patient to Do not share facecloths and hand towels; this will help prevent transmission of
the fungal infection.
 Inform Patient to Do not breast feed while taking this drug without consulting physician.

✓ Allylamine Antifungals

1.

Generic name

ITRACONAZOLE

Brand name

Sporanox

Classification

Allylamine Antifungals

Dosage/frequency and Route

 Pulmonary and Extrapulmonary Blastomycosis, Nonmeningeal Histoplasmosis

Adult: PO 200 mg once daily (increase to max: 200 mg b.i.d. if no apparent improvement). Continue for
at least 3 mo; for life-threatening infections, start with 200 mg t.i.d. for 3 d, then 200–400 mg/d. IV 200
mg b.i.d. infused over 1 h for 4 doses, then 200 mg q.d.
Child: PO 3–5 mg/kg/d for 3–6 mo

 Oropharyngeal Candidiasis

Adult: PO 200 mg daily for 1–2 wk

 Esophageal Candidiasis

Adult: PO 100 mg daily for at least 3 wk (max: 200 mg/d)

 Vaginal Candidiasis

Adult: PO 200 mg q.d. for 3 d

 Onychomycosis

Adult: PO 200 mg q.d. for 3 mo

Mechanism of action

Fungistatic; may also be fungicidal depending on the concentration. Interferes with formation of
ergosterol, the principal sterol in the fungal cell membrane that, when depleted, interrupts membrane
function.

Indication

 Pulmonary and Extrapulmonary Blastomycosis, Nonmeningeal Histoplasmosis

 Oropharyngeal Candidiasis
 Esophageal Candidiasis
 Vaginal Candidiasis

Contraindication

Hypersensitivity to itraconazole; renal failure; pregnancy (category C), lactation

Side effects

 diarrhea.
 constipation.
 gas or bloating.
 heartburn.
 unpleasant taste.
 sore or bleeding gums.
 headache.
 dizziness.

Adverse effects
  CV: Hypertension with higher doses.
 CNS: Headache, dizziness, fatigue, somnolence (euphoria, drowsiness <1%)
 Endocrine: Gynecomastia, hypokalemia (especially with higher doses), hypertriglyceridemia.
 GI: Nausea, vomiting, dyspepsia, abdominal pain, diarrhea, anorexia, flatulence, gastritis;
elevations of serum transaminases, alkaline phosphatase, and bilirubin.
 Urogenital: Decreased libido, impotence.
 Skin: Rash, pruritus.
 Acute Poisoning: Severe toxicity (doses exceeding 400 mg daily have been associated with
higher risk of hypokalemia, hypertension, adrenal insufficiency).

Nursing Responsibility

 Lab tests: C&S tests should be done before initiation of therapy. Drug may be started pending
results. Monitor hepatic functions especially in those with preexisting hepatic abnormalities.
 Monitor for digoxin toxicity when given concurrently with digoxin.
 Monitor PT and INR carefully when given concurrently with warfarin.
 Monitor for S&S of hypersensitivity (see Appendix F); discontinue drug and notify physician if
noted.

2.

Generic name

VORICONAZOLE

Brand name

Vfend

Classification

Allylamine Antifungals

Dosage/frequency and Route

 Aspergillosis

Adult/Geriatric: IV 6 mg/kg q12h day 1, then 4 mg/kg q12h. May reduce to 3 mg/kg q12h if not tolerated
PO >40 kg, 400 mg q12h day 1, then 200 mg q12h. May increase to 300 mg q12h if inadequate response.
<40 kg, 400 mg q12h day 1, then 100 mg q12h. May increase to 150 mg q12h if inadequate response.

 Esophageal Candidiasis

Adult/Geriatric: PO >40 kg, 200 mg q12h for a minimum of 14 d and for at least 7 d after resolution of
symptoms; <40 kg, 100 mg q12h for a minimum of 14 d and for at least 7 d after resolution of
symptoms.
  Dose Adjustment for Concomitant Fosphenytoin or Phenytoin

Adult/Geriatric: IV 6 mg/kg q12h day 1, then 5 mg/kg q12h. PO >40 kg, 400 mg q12h day 1, then 400 mg
q12h. <40 kg, 400 mg q12h day 1, then 200 mg q12h

Mechanism of action

Inhibits fungal cytochrome P-450 enzymes used for an essential step in fungal ergosterol biosynthesis.
The subsequent loss of ergosterol in the fungal cell wall may be responsible for the antifungal activity of
voriconazole

Indication

Treatment of invasive Aspergillosis, esophageal candidiasis, candidemia in nonneutropenic patients and

disseminated skin infections, and abdomen, kidney, bladder wall, and wound infections due to Candida.

Contraindication

Known hypersensitivity to voriconazole; intravenous voriconazole should be avoided in moderate or

severe renal impairment (Clcr <50 mL/min); severe hepatic impairment; children <2 y; history of
galactose intolerance; Lapp lactase deficiency or glucose-galactose malabsorption; concurrent use of
sirolimus; coadministration of the CYP3A4 substrates pimozide or quinidine; concurrent use of rifampin,
rifabutin, carbamazepine and long-acting barbiturates, ergot alkaloids; sunlight (UV) exposure;
pregnancy (category D); lactation.

Side effects

 nausea,
 vomiting,
 diarrhea,
 headache,
 fever, or.
 swelling in your hands, ankles, or feet.

Adverse effects

Body as a Whole: Peripheral edema, fever, chills. CNS: Headache, hallucinations, dizziness.

CV: Tachycardia, hypotension, hypertension, vasodilation.

GI: Nausea, vomiting, abdominal pain, abnormal LFTs, diarrhea, cholestatic jaundice, dry mouth.
Metabolic: Increased alkaline phosphatase, AST, ALT, hypokalemia, hypomagnesemia.

Skin: Rash, pruritus

Special Senses: Abnormal vision (enhanced brightness, blurred vision, or color vision changes),
photophobia.
Nursing Responsibility

 Monitor visual acuity, visual field, and color perception if treatment continues beyond 28 d.
 Withhold drug and notify physician if skin rash develops.
 Monitor cardiovascular status especially with preexisting CV disease.
 Lab tests: Monitor baseline and periodic LFTs including bilirubin; patients who develop abnormal
liver function tests during therapy should be monitored for the development of more severe
hepatic injury. Monitor frequently renal function tests, especially serum creatinine. Monitor
periodic CBC with platelet count, Hct & Hgb, serum electrolytes, alkaline phosphatase, blood
glucose, and lipid profile.
 Concurrent drugs: Monitor PT/INR closely with warfarin as dose adjustments of warfarin may be
needed.
 Monitor frequently blood glucose levels with sulfonylurea drugs as reduction in the
sulfonylurea dosage may be needed.
 Monitor for and report any of the following: S&S of rhabdomyolysis in patient receiving a statin
drug; prolonged sedation in patient receiving a benzodiazepine; S&S of heart block, bradycardia,
or CHF in patient receiving a calcium channel blocker.

3.

Generic name

TERBINAFINE HYDROCHLORIDE

Brand name

Lamisil

Classification

Allylamine Antifungals

Dosage/frequency and Route

 Tinea Pedis, Tinea Cruris, or Tinea Corporis

Adult: Topical Apply q.d. or b.i.d. to affected and immediately surrounding areas until clinical signs and
symptoms are significantly improved (1–7 wk)

 Onychomycosis

Adult: PO 250 mg q.d. times 6 wk for fingernails or times 12 wk for toenails

Mechanism of action

Synthetic antifungal agent that inhibits sterol biosynthesis in fungi and ultimately causes fungal cell
death.

Indication

 Tinea Pedis, Tinea Cruris, or Tinea Corporis

 Onychomycosis

Contraindication

Hypersensitivity to terbinafine; lactation

Side effects

Adverse effects

 Skin: Pruritus, local burning, dryness, rash, vesiculation, redness, contact dermatitis at
application site.
 CNS: Headache.
 GI: Diarrhea, dyspepsia, abdominal pain, liver test abnormalities, liver failure (rare).
Hematologic: Neutropenia (rare).
 Special Senses: Taste disturbances.

Nursing Responsibility

 Monitor for and report increased skin irritation.

 Teach the correct technique for application of cream.
 Inform the patient that medication must be used for full treatment time to be effective
 Inform the patient (if only lactating women to avoid Breastfeeding while taking the drug