Antifungal Agents

Antifungal Agents

What Is a Fungus?

  • Fungus
    • Composed of a rigid cell wall made up of chitin and various polysaccharides, and a cell membrane containing ergosterol
    • Protective layers of the fungal cell make the organism resistant to antibiotics

Patients Susceptible to Fungal Infections

  • Patients with AIDS and AIDS-related complex (ARC)
  • Patients taking immunosuppressant drugs
  • Patients who have undergone transplantation surgery or cancer treatment
  • Members of growing elderly population no longer protected from environmental fungi


  • Culture is needed prior to prescribing antifungal agents
  • Patients on antifungal agents are immuno-compromised at onset

Amphotericin B Indications

  • Aspergillosis
  • Leishmaniasis
  • Cryptococcosis
  • Blastomycosis
  • Moniliasis
  • Coccidioidomycosis
  • Histoplasmosis
  • Mucormycosis
  • Candida infections (topically)

Amphotericin B

  • Indications: progressive, potentially fatal fungal infections
  • Pharmacokinetics: IV form, excreted in the urine
  • Contraindication: kidney disease
  • Adverse reaction: kidney failure

Systemic Antifungal Agents

  • Caspofungin (Cancidas) (IV)
    • Approved for the treatment of invasive aspergillosis in patients who are refractory to other treatments
  • Flucytosine (Ancobon) (oral)
    • Less toxic drug used for the treatment of systemic infections caused by Candida or Cryptococcus
  • Nystatin (Mycostatin, Nilstat) (oral)
    • Used for the treatment of intestinal candidiasis; also available in a number of topical preparations

Voriconazole & Terbinafine

  • Newer agents
  • Voriconazole (Vfend)
    • Available in oral and IV forms
    • Treats invasive aspergillosis and serious infections caused by Scedosporium apiospermum and Fusarium species
  • Terbinafine (Lamisil)
    • Blocks the formation of ergosterol
    • Inhibits a CYP2D6 enzyme system
    • Oral drug for the treatment of onychomycosis of the toenail or fingernail


  • Newer class of drugs used to treat systemic fungal infections
  • Less toxic than amphotericin B
  • Less effective than amphotericin B

Ketoconazole (Nizoral)

  • Used orally to treat many of the same mycoses as amphotericin B
  • Works by blocking the activity of a steroid in the fungal wall
  • Has side effect of blocking the activity of human steroids, including testosterone and cortisol
  • Pharmacokinetics: absorbed from the GI tract, metabolized in the liver, excreted in the feces
  • Contraindications: not drug of choice for patients with endocrine or fertility problems
  • Adverse reaction: hepatic toxicity
  • Drug-to-drug interactions: many

Fluconazole (Diflucan)

  • Not associated with the endocrine problems seen with ketoconazole
  • Used to treat candidiasis, cryptococcal meningitis, and other systemic fungal infections
  • Prophylactic agent for reducing the incidence of candidiasis in bone marrow transplant recipients
  • Pharmacokinetics: available in oral and IV preparations, excreted unchanged in the urine
  • Contraindications: renal dysfunction
  • Adverse reactions:
  • Drug-to-drug interactions: inhibits CYP450 and may be associated with drug-to-drug interactions

Itraconazole (Sporanox)

  • An oral agent used for the treatment of assorted systemic mycoses
  • Associated with hepatic failure
  • Slowly absorbed from the GI tract, it is metabolized in the liver by the CYP450 system
  • Excreted in the urine and feces

Sites of Action of Antifungal Agents

Sites of Action of Antifungal Agents

Sites of Action of Antifungal Agents

Overall Contraindications to Systemic Antifungal Agents

  • Anyone with a known allergy
  • Pregnant or lactating women (with the exception of terbinafine for life-threatening infections)
  • Patients with renal or liver disease
    • Drug metabolism or excretion may be altered, or condition may worsen as a result of the actions of the drug

Overall Adverse Reactions to Systemic Antifungal Agents

  • CNS effects
    • Headache, dizziness, fever, shaking, and chills
  • GI effects
    • Nausea, vomiting, dyspepsia, and anorexia
  • Hepatic dysfunction
  • Dermatologic effects
    • Rash and pruritus associated with local irritation
  • Renal dysfunction

Topical Antifungal Infections

  • Caused by dermatophytes
  • Tinea infections (ringworm)
    • Athlete‚Äôs foot (tinea pedis)
    • Jock itch (tinea cruris)
  • Candida
    • Yeast infections of the mouth and vagina

Topical Antifungal Agents

  • Action
    • Work to alter the cell permeability of the fungus, causing prevention of replication and fungal death
  • Indication
    • Indicated only for local treatment of mycoses, including tinea infection
  • Contraindication/caution
    • Limited to known allergy to any antifungal agent
  • Adverse effects
    • Local effects include irritation, burning, rash, and swelling
    • When taken as a suppository or troche, nausea, vomiting, hepatic dysfunction, urinary frequency, burning, and change in sexual activity can occur
  • Drug-to-drug interactions
    • None reported

Prototype Antifungal Agent





Use of Antifungals Across the Lifespan

Drug Therapy Across the Lifespan

Drug Therapy Across the Lifespan

Nursing Considerations for Systemic Antifungal Agents

  • Assessment (history and physical exam)
  • Nursing diagnosis
  • Implementation
  • Evaluation

Nursing Considerations for Topical Antifungal Agents

  • Assessment (history and physical exam)
  • Nursing diagnosis
  • Implementation
  • Evaluation
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