Thérapeutique des mycoses profondes (à l'exception des aspergilloses et des fusarioses)

Abstract

Systemic fungal infections frequency is increasing, particulary in immunosuppressed patients. The reference molecule is still conventional amphotericin B IV (0,7–1 mg/kg/day), despite has toxicity (chills, fever, dizzyness, renal failure). New lipidic formulations of amphotericin B (Ambisome®, Abelcet®) have less toxicity and efficacy at least as good as conventional amphotericin B IV. These new therapies are still expensive, and we need cost-benefice studies to define there place in invasive fungal infections treatment. Fluconazole, which biodisponibility per os is good, can be used in second line, after amphotericin B treatment (cryptococcal meningitis for exemple) or in first line treatment for candidemia if Candida is susceptible to fluconazole. High doses fluconazole (400–800 mg/day) can be used in case of reduced suceptibility, or in maintenance therapy for cryptoccocal infection. Tolerance of high-doses fluconazole therapy is good. Itraconazole has variable biodisponibility, and must be used in second line treatment, for exemple in œsophagal candidosis in immunocompromised patients (400 mg/day) or in maintenance therapy for histoplasmosis or penicilliosis. Interactions with others treatments are numerous. Flucytosine (5FC) is always used in association with other antifungal, because of the high risk of resistance mutation selection in monotherapy, and can be used with amphotericin B IV in serious invasive fugal infections like crytococcal meningitis.