TABLE 9.
Antifungal therapy of osteoarticular fungal infections in infants and childrena
| Type of infection | Recommended drug treatment(s) and duration(s) | Pediatric dose(s) | Alternative treatment | Pediatric dose(s) for alternative treatment | Description |
|---|---|---|---|---|---|
| Candida osteomyelitis | Fluconazole for 6–12 mo or echinocandin for 2 wks followed by fluconazole for 6–12 mo (IDSA, strong recommendation; low-quality evidence) | Fluconazole at 12 mg/kg; caspofungin with loading dose of 70 mg/m2 followed by 50 mg/m2/day; micafungin at 2 mg/kg/day with the option to increase the dose to 4 mg/kg/day in children weighing <40 kg; neonates, 10 mg/kg/day or higher | Lipid formulation of AmB for at least 2 wks followed by fluconazole daily for 6–12 mo (IDSA, weak recommendation; low-quality evidence) | Lipid formulation of AmB at 3–5 mg/kg/day | Surgical debridement indication in selected cases (strong recommendation; low-quality evidence) |
| Candida septic arthritis | Fluconazole for 6 wks or echinocandin for 2 wks followed by fluconazole for at least 4 wks (IDSA, strong recommendation; low-quality evidence) | Fluconazole at 12 mg/kg/day; caspofungin with a loading dose of 70 mg/m2 followed by 50 mg/m2/day; micafungin at 2 mg/kg/day, with the option to increase the dose to 4 mg/kg/day in children weighing <40 kg, and 10 mg/kg/day for neonates | Lipid formulation of AmB daily for at least 2 wks followed by fluconazole daily for 4 wks (IDSA, weak recommendation; low-quality evidence) | Lipid formulation of AmB at 3–5 mg/kg/day | Surgical drainage indication for all cases of septic arthritis (strong recommendation; moderate-quality evidence); prosthetic device removal is recommended (strong recommendation; moderate quality of evidence); alternative chronic suppression with fluconazole (6 mg/kg) if the strain is susceptible |
| Aspergillus osteomyelitis | Voriconazole for a durationb of a minimum of 6–12 wks depending on the degree/duration of immunosuppression, site of disease, and evidence of disease improvement; longer courses (>6 mo) are frequently necessary (strong recommendation; low-quality evidence) | Loading dose of 9 mg/kg BID followed by 8 mg/kg BID; oral dose of 9 mg/kg BID (max dose of 350 mg) | Alternative of liposomal AmB; salvage with ABLC, caspofungin, micafungin, posaconazole, Itraconazole | ABLC at 5 mg/kg/day i.v. (ECILc guidelines); posaconazole at 800 mg/day orally q6h or q12h in children aged ≤13 yrs (ECIL); itraconazole at 5 mg/kg/day orally (children aged ≤2 yrs) q12h | Surgical intervention is recommended where feasible (strong recommendation; moderate-quality evidence) |
| Aspergillus septic arthritis | Voriconazole for a durationb of a minimum of 6–12 wks depending on the degree/duration of immunosuppression, site of disease, and evidence of disease improvement; longer courses (>6 mo) are frequently necessary (strong recommendation; low-quality evidence) | Loading dose of 9 mg/kg q12h followed by 8 mg/kg q12h; oral dose of 9 mg/kg q12h (max dose of 350 mg) | Alternative of liposomal AmB; salvage with ABLC, caspofungin, micafungin, posaconazole, itraconazole | ABLC at 5 mg/kg/day i.v. (ECIL guidelines); posaconazole at 800 mg/day orally q6h or q12h in children aged ≤13 yrs (ECIL); itraconazole at 5 mg/kg/day orally (children aged ≤2 yrs) q12h | Surgical intervention is recommended where feasible (strong recommendation; moderate-quality evidence) |