5.2. Antifungal drugs
5.2.1. Triazole antifungals
Restricted to use on the advice of microbiologist/ haematologist primarily in immuno-compromised patients with progressive, possibly life-threatening infections. Treatment of candidaemia in non-neutropenic patients is restricted to those who cannot tolerate amphotericin B therapy or who are at an increased risk of serious side effects with amphotericin.
Prophylaxis of invasive fungal infections in high risk allogeneic hematopoietic stem cell transplant (HSCT) recipients remains non-Formulary.
The shared care protocol for prescribing of voriconazole for invasive aspergillosis is currently suspended and prescribing should be routinely undertaken in the acute setting.
Restrictions: Restricted to specialist use only. Use for the prophylaxis of invasive fungal infections in immunocompromised patients is restricted to patients in whom there is a specific risk of aspergillus infection or where fluconazole or itraconazole are not tolerated in accordance with local protocol. In addition use for treatment is restricted to patients in whom there is a specific risk of Aspergillus infection or where fluconazole or itraconazole are not tolerated on the advice of local microbiologists or specialists in infectious diseases.
Different formulations of posaconazole may differ in dosing and absorption and are not interchangable.
Restrictions: The use of itraconazole in the treatment of fungal nail infections is non-Formulary.
5.2.2. Imidazole antifungals
5.2.3. Polyene antifungals
Restrictions: Restricted to specialist use only. Abelcet® and AmBisome® are restricted to use in systemic mycoses when toxicity (especially nephrotoxicity) precludes the use of conventional amphotericin. AmBisome® is not approved for the empirical treatment of fungal infections in the febrile neutropenic patient.
Prescribe intravenous preparations by brand name.
5.2.4. Echinocandin antifungals
Restrictions: Restricted to specialist use only. Caspofungin is restricted to adult and paediatric patients with fluconazole-resistant Candida infection unresponsive to or who cannot tolerate amphotericin B therapy. It is not recommended by SMC for invasive aspergillosis. Restricted for empirical therapy for presumed fungal infections in febrile, neutropenic adult and paediatric patients on the advice of microbiologists or specialists in infectious diseases.
Restrictions: Restricted to specialist use only. The treatment of invasive candidasis in adults is restricted to use on the advice of a consultant microbiologist where other treatment options are unsuccessful or inappropriate.
Restrictions: Restricted to specialist use only for the treatment of invasive candidiasis in adults, elderly, and children (including neonates) where other treatment options are unsuccessful or inappropriate. It is restricted to specialist use only on the advice of a consultant microbiologist or infectious disease physician.
Use for the treatment of oesophageal candidiasis, or for the prophylaxis of Candida infection in patients undergoing allogeneic haematopoietic stem cell transplantation or patients who are expected to have for 10 or more days is not recommended by SMC and is non-Formulary.
5.2.5. Other antifungals
Terbinafine is particularly useful for systemic treatment of skin and nail fungal infections.