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Uses

Aspergillosis

Treatment of invasive aspergillosis.

A drug of choice, especially for severe pulmonary and disseminated infections (e.g., endocarditis, osteomyelitis, CNS, ocular, cutaneous). Not usually indicated for allergic bronchopulmonary aspergillosis or other noninvasive forms.

Invasive aspergillosis (especially in immunocompromised patients) is difficult to diagnose and treat. Has been used in conjunction with flucytosine or rifampin in infections that did not respond to amphotericin B alone; unclear whether concomitant therapy offers any benefits and there are concerns related to possible drug interactions between amphotericin B and flucytosine. Also has been used in conjunction with itraconazole (generally administered sequentially); there are concerns related to possible drug interactions between amphotericin B and itraconazole.

Blastomycosis

Treatment of North American blastomycosis caused by Blastomyces dermatitidis.

A drug of choice, especially for severe infections and those involving the CNS.

Candida Infections

Treatment of disseminated or invasive infections caused by Candida, including candidemia, endocarditis, meningitis, arthritis, peritonitis, and intraabdominal abscesses. Generally effective against infections caused by C. albicans, C. glabrata, C. krusei, C. parapsilosis, or C. tropicalis.

A drug of choice for systemic invasive candidiasis. Choice of antifungal for initial treatment should take into consideration local and/or institutional epidemiologic data regarding prevalence of the various Candida and their patterns of resistance, the colonization status of the patient, severity and duration of neutropenia or immunosuppression, and history of prior use of azoles (e.g., fluconazole). Amphotericin B generally preferred for severe candidemia in patients who have infections caused by strains that may be fluconazole-resistant (e.g., C. krusei, C. glabrata), patients who have recently received fluconazole, and immunocompromised patients such as those with HIV infection; fluconazole may be preferred in infections caused by C. lusitaniae.

Mucocutaneous or noninvasive Candida infections (e.g., oral thrush, esophageal candidiasis, vaginal candidiasis) usually can be adequately treated with oral antifungals (e.g., fluconazole, ketoconazole, itraconazole) or topical antifungals (e.g., clotrimazole oral lozenges, nystatin oral suspension, amphotericin B oral suspension). Severe mucocutaneous candidiasis, infections caused by azole-resistant Candida or infections that fail to respond to such therapy may require IV amphotericin B.

Treatment of candiduria; administered by bladder irrigation†. Antifungal not necessarily indicated in asymptomatic candiduria, but may be indicated in patients with symptoms or rapidly worsening underlying disease, patients undergoing renal transplantation, low-birthweight infants, patients undergoing urologic manipulations, or patients with factors that predispose them to persistent candiduria (e.g., neutropenia, diabetic mellitus, urinary catheterization).

Treatment of candidal endophthalmitis, especially when lesions are advancing rapidly or threaten the macula; used with or without flucytosine.

Coccidioidomycosis

Treatment of coccidioidomycosis caused by Coccidioides immitis.

A drug of choice, especially for initial treatment of severe coccidioidomycosis in immunocompromised patients (e.g., HIV-infected patients).

May be ineffective for treatment of coccidioidal meningitis if given only by IV route; conventional amphotericin B given by intrathecal lumbar or cisternal injection† or by subcutaneously placed ventricular reservoir (Ommaya reservoir)† in conjunction with IV administration, usually is necessary.

Alternative to oral fluconazole for long-term suppressive or chronic maintenance therapy (secondary prophylaxis)† to prevent recurrence in HIV-infected adults, adolescents, and pediatric patients who have had documented, adequately treated coccidioidomycosis. May be the preferred agent when secondary prophylaxis against coccidioidomycosis is indicated in an HIV-infected pregnant woman, especially during the first trimester.

Cryptococcal Infections

Treatment of infections caused by Cryptococcus neoformans.

Drug of choice for initial treatment of cryptococcal infections, including meningitis. Because of reported in vitro and in vivo synergism, has been used in conjunction with flucytosine for initial treatment, including in HIV-infected patients.

Alternative to oral fluconazole for long-term suppressive or chronic maintenance therapy (secondary prophylaxis)† to prevent relapse of cryptococcal meningitis in HIV-infected adults, adolescents, and pediatric patients. May be the preferred agent when secondary prophylaxis against cryptococcosis is indicated in an HIV-infected pregnant woman, especially during the first trimester.

Histoplasmosis

Treatment of disseminated histoplasmosis caused by Histoplasma capsulatum.

A drug of choice, especially for initial treatment of severe, life-threatening histoplasmosis in immunocompromised patients such as those with HIV infection.

Treatment of meningitis caused by H. capsulatum (IV conventional amphotericin B alone or in conjunction with intrathecal† conventional amphotericin B).

Alternative to oral itraconazole for long-term suppressive or chronic maintenance therapy (secondary prophylaxis)† to prevent recurrence in HIV-infected adults, adolescents, and pediatric patients who have documented, adequately treated histoplasmosis. May be the preferred agent when secondary prophylaxis against histoplasmosis is indicated in an HIV-infected pregnant woman, especially during the first trimester.

Paracoccidioidomycosis

Treatment of paracoccidioidomycosis† (South American blastomycosis) caused by Paracoccidioides brasiliensis.

Oral itraconazole may be drug of choice for treatment of paracoccidioidomycosis; amphotericin B generally preferred for initial treatment of severe infections and in HIV-infected patients.

Sporotrichosis

Treatment of disseminated, pulmonary, osteoarticular, and meningeal sporotrichosis caused by Sporothrix schenckii.

A drug of choice for initial treatment of systemic sporotrichosis, including severe, life-threatening infections, whenever there is CNS involvement, and in HIV-infected patients. Usually not indicated for treatment of cutaneous, lymphocutaneous, or mild pulmonary or osteoarticular sporotrichosis since these forms of the disease generally can be treated with an oral azole (e.g., itraconazole).

Zygomycosis

Treatment of zygomycosis, including mucormycosis, caused by susceptible species of Absidia, Mucor, or Rhizopus and infections caused by susceptible species of Conidiobolus or Basidiobolus.

Drug of choice for most of these infections. Severe cases of GI basidiobolomycosis caused by Basidiobolus ranarum may not respond to amphotericin B. GI basidiobolomycosis has been successfully treated with oral itraconazole after partial surgical resection of the GI tract.

Empiric Therapy in Febrile Neutropenic Patients

Empiric therapy of presumed fungal infections in febrile, neutropenic patients†, including cancer patients and bone marrow transplant (BMT) or solid organ transplant recipients.

Prevention of Fungal Infections in Transplant or Cancer Patients

Prevention of fungal infections (e.g., aspergillosis, candidiasis) in neutropenic cancer patients or patients undergoing BMT or solid organ transplantation†.

Use of primary antifungal prophylaxis in cancer patients undergoing myelosuppressive therapy or patients undergoing BMT or solid organ transplantation remains controversial; such prophylaxis may predispose the patient to colonization with resistant fungi and/or result in emergence of highly resistant organisms. If primary prophylaxis is warranted (e.g., patients in institutions that have a high incidence of fungal infections or circumstances where the frequency of systemic candidal infections is high), an oral azole may be preferred over amphotericin B. Consider that widespread use of fluconazole for prophylaxis in immunocompromised patients may result in an increased incidence of colonization with fluconazole-resistant strains.

Leishmaniasis

Treatment of American cutaneous leishmaniasis caused by Leishmania braziliensis or L. mexicana and for mucocutaneous leishmaniasis caused by L. braziliensis. Usual drugs of choice are pentavalent antimony compounds (e.g., sodium stibogluconate [not commercially available in the US], meglumine antimonate [not commercially available in the US]); amphotericin B also a drug of choice for these infections.

Treatment of visceral leishmaniasis (kala-azar). Usual drugs of choice for initial treatment of visceral leishmaniasis caused by L. donovani (usually endemic in Asia and Africa), L. infantum (usually endemic in the Mediterranean basin), or L. chagasi (usually endemic in Latin America) are pentavalent antimony compounds, but resistance and treatment failures are becoming increasingly common. Both IV amphotericin B and pentamidine are considered alternatives and have been effective in patients who failed to respond to antimony compounds.

Primary Amebic Meningoencephalitis

Treatment of primary amebic meningoencephalitis caused by Naegleria fowleri†.

These infections usually rapidly fatal, but there have been a few reports of successful treatment with conventional amphotericin B used alone or in conjunction with other drugs (e.g., rifampin and chloramphenicol; rifampin and ketoconazole; miconazole [no longer commercially available], rifampin, and sulfadiazine). Concomitant IV and intrathecal conventional amphotericin B has been recommended.