Mould infection
Aspergillus, Lomentospora and Scedosporium species are the most likely mould pathogens in immunocompromised adults. Antifungal prophylaxis for mould infection also protects against infection with yeast (eg Candida species). To assess if antifungal prophylaxis for mould infection is required, see Assessing the need for antimicrobial prophylaxis in immunocompromised adults without HIV infection.
Seek expert advice on antifungal prophylaxis after liver transplant, lung or heart–lung transplant or for patients with acute lymphocytic leukaemia (ALL) treated with vinca alkaloids (eg vincristine). An alternative to azole therapy (eg amphotericin B liposomal or lipid complex, an echinocandin) may be required in these patients—refer to local protocols.
For antifungal prophylaxis against mould infection in other patients, use:
1 posaconazole modified-release tablets 300 mg orally, 12-hourly for two doses, then 300 mg daily; for duration of prophylaxis, see Assessing the need for antimicrobial prophylaxis in immunocompromised adults without HIV infection1 fungal infection prophylaxis (immunocompromised adult without HIV) posaconazole
OR
2 voriconazole tablets (adult 40 kg or more) 400 mg orally, 12-hourly for two doses, then 200 mg orally, 12-hourly; for duration of prophylaxis, see Assessing the need for antimicrobial prophylaxis in immunocompromised adults without HIV infection. Monitor plasma concentration (see Monitoring antimicrobial blood concentrations). fungal infection prophylaxis (immunocompromised adult without HIV) voriconazole
For patients who cannot swallow a tablet formulation, use an oral liquid formulation:
1 posaconazole liquid 200 mg orally with fatty food or an acidic beverage, 8-hourly; for duration of prophylaxis, see Assessing the need for antimicrobial prophylaxis in immunocompromised adults without HIV infection. Monitor plasma concentration (see Monitoring antimicrobial blood concentrations)1 posaconazole
OR
2 voriconazole liquid (adult 40 kg or more) 400 mg orally, 12-hourly for two doses, then 200 mg orally, 12-hourly; for duration of prophylaxis, see Assessing the need for antimicrobial prophylaxis in immunocompromised adults without HIV infection. Monitor plasma concentration (see Monitoring antimicrobial blood concentrations). voriconazole
If oral therapy is not possible, use:
1 posaconazole 300 mg intravenously, daily; give a loading dose of 300 mg intravenously 12-hourly for two doses if not switching from oral posaconazole. For duration of prophylaxis, see Assessing the need for antimicrobial prophylaxis in immunocompromised adults without HIV infection posaconazole
OR
1 voriconazole 4 mg/kg intravenously, 12-hourly; give a loading dose of 6 mg/kg intravenously 12-hourly for two doses if not switching from oral voriconazole. For dosage adjustment in adults with kidney impairment, see voriconazole intravenous dosage adjustment. For duration of prophylaxis, see Assessing the need for antimicrobial prophylaxis in immunocompromised adults without HIV infection. voriconazole
Switch to oral therapy when the patient is able to tolerate and absorb oral therapy.
If intravenous therapy is required but an azole cannot be used, seek expert advice. Options include amphotericin B liposomal or lipid complex, or an echinocandin, but evidence is limited.