Fungal in children
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antifungal treatment children pediatric
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Antifungal Treatment & Dosing in Children
Below is a structured overview of antifungal agents used in pediatric patients, organized by drug class, with dosing, indications, and key pediatric considerations.
1. Polyenes
Amphotericin B Deoxycholate (conventional)
- Dose: 1.0 mg/kg/day IV (or 1.5 mg/kg every other day; max 1.5 mg/kg/day); infuse over 2-4 hours
- Intrathecal (IT): 0.01-0.025 mg, slowly increased to 0.5 mg, twice/week
- Indications: Severe systemic fungal infections, cryptococcal meningitis (induction), mucormycosis
- Adverse effects: Fever, chills, phlebitis, GI upset, hypokalemia, anemia, nephrotoxicity, cardiac arrhythmias, neurotoxicity, anaphylaxis
Amphotericin B Lipid Complex (Abelcet)
- Dose: 3-5 mg/kg/day IV, infused over 2 hours
- Advantage: Less nephrotoxicity than conventional; hepatotoxicity reported
Liposomal Amphotericin B (AmBisome) - preferred in children
- Dose: 3-5 mg/kg IV, infused over 1-2 hours
- Prophylaxis: 1 mg/kg/dose every other day OR 2.5 mg/kg/dose twice/week
- Mucormycosis: Doses up to 10 mg/kg have been used
- Cryptococcosis (pediatric induction): 5-7.5 mg/kg/day in combination with flucytosine
- Advantage: Best-tolerated amphotericin formulation; preferred in pediatrics
2. Azoles
Fluconazole
| Indication | Pediatric Dose | Notes |
|---|---|---|
| Oropharyngeal candidiasis | 6 mg/kg on day 1, then 3 mg/kg/day | Max adult dose: 200 mg |
| Esophageal candidiasis | 6 mg/kg/day | Min 3 weeks, 2 weeks after symptom resolution |
| Cryptococcal meningitis (consolidation) | 10-12 mg/kg/day in 2 divided doses | Max 800 mg/day; min 8 weeks |
| Cryptococcal suppression (HIV) | 6 mg/kg/day | Max 400 mg |
| Tinea capitis (2nd-line) | 3-6 mg/kg/day | 3-6 weeks; do not exceed adult dose |
- Route: IV or PO (absorption not pH-dependent, unlike itraconazole)
- A loading dose of twice the daily maintenance dose is given on day 1
- Children are generally treated with mg/kg doses equivalent to adult doses
Itraconazole
- Dose: 3-5 mg/kg/day orally
- Doses >200 mg should be divided into two daily doses
- Tinea capitis: Continuously for 2-4 weeks OR pulse dosing (1-3 week pulses with 3-week drug-free intervals)
- Capsules should be taken with a full meal; oral solution on an empty stomach
- Key note: Ketoconazole is no longer routinely used in children due to hepatotoxicity; itraconazole or fluconazole preferred
Voriconazole (age >= 2 years)
| Age/Weight Group | IV Dose | Oral Dose |
|---|---|---|
| Adults | 4 mg/kg IV q12h (loading: 6 mg/kg x2) | 200 mg q12h |
| Children ≤11 yr OR 12-14 yr weighing <50 kg | 8 mg/kg IV q12h (loading: 9 mg/kg x2) | 8 mg/kg (max 350 mg) q12h |
- Not approved under age 2
- Dose adjustments needed for hepatic dysfunction
- Oral preferred in renal impairment (avoid IV vehicle accumulation)
- Immunocompromised children (e.g., stem cell transplant): same oral dose used for prophylaxis twice daily
Posaconazole
- Approved for age ≥13 years
- Oral suspension: 40 mg/mL; delayed-release tablets: 100 mg
- Prophylaxis of invasive fungal infections: 200 mg TID (oral suspension) with food
- IV formulation approved for adults only (≥18 yr)
Isavuconazole
- Safety and effectiveness in patients under 18 years not established
3. Echinocandins
Caspofungin
| Population | Dose |
|---|---|
| Adults (≥18 yr) | 70 mg loading on day 1, then 50 mg/day |
| Pediatric (children) | 3 mg/kg loading on day 1, then 1.5 mg/kg/day; max 100 mg/day |
| Esophageal candidiasis (pediatric) | 1.5 mg/kg loading, then 0.75 mg/kg/day; max 50 mg/day |
- IV only; well-tolerated in children
- Adverse effects: diarrhea, rash, hepatic enzyme elevations, hypokalemia, infusion reactions
Anidulafungin
| Population | Dose |
|---|---|
| Adults/adolescents ≥12 yr - candidemia | 200 mg day 1, then 100 mg/day (≥14 days after last positive culture) |
| Adults/adolescents ≥12 yr - esophageal candidiasis | 100 mg day 1, then 50 mg/day (min 14 days) |
| Children ≥2 yr through 11 yr | Loading dose day 1, then 0.75 mg/kg/day; max loading and daily dose ≤50 mg |
- Infusion rate must not exceed 1.1 mg/min (high alcohol content in IV vehicle)
- Efficacy and safety not established for children under 4 months of age
Micafungin
- Also used in pediatrics (including neonates) but specific dosing details not extracted from this source - doses typically 2-4 mg/kg/day IV in children
4. Topical Antifungals (Superficial Infections)
| Drug | Notes for Children |
|---|---|
| Clotrimazole 1% | Safe; 1-2x daily for 2-4 weeks; avoid steroid combinations |
| Ciclopirox | Safety not established <10 years old |
| Butenafine | Safety not established <12 years old |
| Nystatin suspension | Oral suspension held in mouth 4x/day; essentially no systemic absorption |
5. Pyrimidine: Flucytosine (5-FC)
- Dose: 25 mg/kg/dose, 4 times/day (when renal function is normal)
- Use: Always in combination with amphotericin B (for cryptococcal meningitis induction - never monotherapy)
- Monitoring: Blood counts and serum peak flucytosine levels (target: 40-60 mcg/mL, 2 hours post-dose) to prevent neutropenia
6. Oral Terbinafine (for dermatophytes)
| Infection | Duration |
|---|---|
| Toenail onychomycosis | 12 weeks |
| Fingernail onychomycosis | 6 weeks |
| Superficial tinea | 2 weeks |
| Tinea capitis | 3-6 weeks continuously |
- Dosing for adults and children is weight-based (Table 127.15 in Dermatology reference)
Key Pediatric Principles
- Weight-based dosing is standard for nearly all antifungals in children; use mg/kg and always check against the adult maximum dose
- Liposomal amphotericin B is the preferred formulation in pediatrics for serious infections - better tolerability than conventional
- Voriconazole requires higher mg/kg doses in young children (≤11 yr) than adults due to faster drug metabolism
- Therapeutic drug monitoring (TDM) is recommended for voriconazole and flucytosine in pediatric patients
- Isavuconazole and IV posaconazole are not approved under 18 years; oral posaconazole is approved from age 13
- For cryptococcal meningitis: Induction (amphotericin B + flucytosine, ≥2 weeks) → Consolidation (fluconazole 10-12 mg/kg/day, ≥8 weeks) → Maintenance (fluconazole 6 mg/kg/day)
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