Antifungal drugs

At a glance

• Fungi are eukaryotes, so selective targets are few. The drugs hit ergosterol (the fungal equivalent of cholesterol), its synthesis, or the beta-glucan cell wall.
• Azoles inhibit fungal CYP51 and, to varying degrees, human CYP3A4. That makes them the antimicrobials with the most dangerous interactions in transplant and haematology patients.
• Echinocandins are first-line for candidaemia; voriconazole (or isavuconazole) for invasive aspergillosis; liposomal amphotericin plus flucytosine for cryptococcal meningitis; high-dose liposomal amphotericin plus surgical debridement for mucormycosis, with isavuconazole or posaconazole as alternatives or step-down.