1. Antifungal Drugs Fungal infectious occur due to :
1- Abuse of broad spectrum antibiotics
2- Decrease in the patient immunity

2. Types of fungal infections
1. Superficial : Affect skin – mucous membrane.e.g.
Tinea versicolor
Dermatophytes : Fungi that affect keratin layer of skin, hair, nail.e.g.tinea pedis ,ring worm infection
Candidiasis : Yeast-like, oral thrush, vulvo-vaginitis , nail infections.

3. 2- Deep infections
Affect internal organs as : lung ,heart , brain leading to pneumonia , endocarditis , meningitis.

4. Classification of Antifungal Drugs
1- Antifungal Antibiotics :
Griseofulvin
Polyene macrolide : Amphotericin- B & Nystatin
2- Synthetic :
Azoles :
A) Imidazoles : Ketoconazole , Miconazole
B) Triazoles : Fluconazole , Itraconazole

5. Synthetic Antifungal ( contin…)
Flucytosine
Squalene epoxidase inhibitors : e.g.
Terbinafine & Naftifine.

6. Classification According to Route of Administration
Systemic :
Griseofulvin , Amphotericin- B , Ketoconazole , Fluconazole , Terbinafine.
Topical
In candidiasis :
Imidazoles : Ketoconazole , Miconazole.
Triazoles : Terconazole.
Polyene macrolides : Nystatin , Amphotericin-B
Gentian violet : Has antifungal & antibacterial.

7. In Dermatophytes :
Squalene epoxidase inhibitors : Terbinafine &
Naftifine.
Tolnaftate.
White field ointment : 12% Benzoic acid & 6% Salicylic acid .
Castellani paint.

8. Amphotericin B Amphotericin A & B are antifungal antibiotics.
Amphotericin A is not used clinically.
It is a natural polyene macrolide
(polyene = many double bonds )
(macrolide = containing a large lactone ring )

9. Pharmacokinetics
Poorly absorbed orally , is effective for fungal infection of gastrointestinal tract.
For systemic infections given as slow I.V.I.
Highly bound to plasma protein .
Poorly crossing BBB.
Metabolized in liver
Excreted slowly in urine over a period of several days.
Half-life 15 days.

10. Mechanism of action It is a selective fungicidal drug.
Disrupt fungal cell membrane by binding to ergosterol , so alters the permeability of the cell membrane leading to leakage of intracellular ions & macromolecules ( cell death ).

11. Resistance to amphotericin B
If ergosterol binding is impaired either by :
Decreasing the membrane concentration of ergosterol.
Or by modyfing the sterol target molecule.

12. Adverse Effects 1- Immediate reactions ( Infusion –related toxicity ).
Fever, muscle spasm, vomiting ,headache, hypotension.
Can be avoided by :
A. Slowing the infusion
B. Decreasing the daily dose
C. Premedication with antipyretics, antihistamincs or corticosteroids.
D. A test dose.

13. 2- Slower toxicity
Most serious is renal toxicity (nearly in all patients ).
Hypokalemia
Hypomagnesaemia
Impaired liver functions
Thrombocytopenia
Anemia

14. Clinical uses Has a broad spectrum of activity & fungicidal action.
The drug of choice for life-threatening mycotic infections.
For induction regimen for serious fungal infection.
Also, for chronic therapy & preventive therapy of relapse.
In cancer patients with neutropenia who remain febrile on broad –spectrum antibiotics.

15. Routes of Administration
1- Slow I.V.I. For systemic fungal disease.
2- Intrathecal for fungal C.N.S. infections.
Topical drops & direct subconjunctival injection for Mycotic corneal ulcers & keratitis.
3- Local injection into the joint in fungal arthritis.
4- Bladder irrigation in Candiduria.

16. Liposomal preparations of amphotericin B
Amphotericin B is packaged in a lipid- associated delivery system to reduce binding to human cell membrane , so reducing :
A. Nephrotoxicity
B. Infusion toxicity
Also, more effective
More expensive

17. Nystatin
It is a polyene macrolide ,similar in structure & mechanism to amphotericin B.
Too toxic for systemic use.
Used only topically.
It is available as creams, ointment , suppositories & other preparations.
Not significantly absorbed from skin, mucous membrane, GIT .

18. Clinical uses
Prevent or treat superficial candidiasis of mouth, esophagus, intestinal tract.
Vaginal candidiasis
Can be used in combination with antibacterial agents & corticosteroids.

19. Azoles
A group of synthetic fungistatic agents with a broad spectrum of activity .
They have antibacterial , antiprotozoal anthelminthic & antifungal activity .

20. Mechanism of Action
1-Inhibit the fungal cytochrome P450 enzyme, (α-demethylase) which is responsible for converting lanosterol to ergosterol ( the main sterol in fungal cell membrane ).
2- Inhibition of mitochondrial cytochrome oxidase leading to accumulation of peroxides that cause autodigestion of the fungus.
3- Imidazoles may alter RNA& DNA metabolism.

21. Azoles
They are antibacterial , antiprotozoal, anthelminthic & antifungal.
They are fungistatic agents.
They are classified into :
Imidazole group
Triazole group

22. Imidazoles Ketoconazole Miconazole Clotrimazole
They lack selectivity ,they inhibit human gonadal and steroid synthesis leading to decrease testosterone & cortisol production.
Also, inhibit human P-450 hepatic enzyme.

23. Ketoconazole Well absorbed orally .
Bioavailability is decreased with antacids, H2 blockers , proton pump inhibitors & food .
Cola drinks improve absorption in patients with achlorhydria.
Half-life increases with the dose , it is (7-8 hrs).

24. Ketoconazole (cont.)
Inactivated in liver & excreted in bile (feces ) & urine.
Does not cross BBB.

25. Clinical uses
Used topically or systematic (oral route only ) to treat :
1- Oral & vaginal candidiasis.
2- Dermatophytosis.
3- Systemic mycoses & mucocutaneous candidiasis.

26. Adverse Effects Nausea, vomiting ,anorexia Hepatotoxic
Inhibits human P 450 enzymes
Inhibits adrenal & gonadal steroids leading to :
Menstrual irregularities
Loss of libido
Impotence
Gynaecomastia in males

27. Contraindications & Drug interactions
Contraindicated in :
Prgnancy, lactation ,hepatic dysfunction
Interact with enzyme inhibitors , enzyme inducers.
H2 blockers & antacids decrease its absorption

28. Triazoles Fluconazole Itraconazole Voriconazole They are : Selective
Resistant to degradation
Causing less endocrine disturbance

29. Itraconazole Lacks endocrine side effects
Has a broad spectrum activity
Given orally & IV
Food increases its absorption
Metabolized in liver to active metabolite
Highly lipid soluble ,well distributed to bone, sputum ,adipose tissues.
Can not cross BBB

30. Itraconazole (cont.) Half-life 30-40 hours
Used orally in dermatophytosis & vulvo-vaginal candidiasis.
IV only in serious infections.
Effective in AIDS-associated histoplasmosis
Side effects :
Nausea, vomiting, hypokalemia, hypertension, edema, inhibits the metabolism of many drugs as oral anticoagulants.

31. Fluconazole Water soluble Completely absorbed from GIT
Excellent bioavailability after oral administration
Bioavailability is not affected by food or gastric PH
Conc. in plasma is same by oral or IV route
Has the least effect on hepatic microsomal enzymes

32. Fluconazole (cont.) Drug interactions are less common
Penetrates well BBB so, it is the drug of choice of cryptococcal meningitis
Safely given in patients receiving bone marrow transplants (reducing fungal infections)
Excreted mainly through kidney
Half-life hours
Resistance is not a problem

33. Clinical uses Candidiasis
( is effective in all forms of mucocutaneous candidiasis)
Cryptococcus meningitis
Histoplasmosis, blastomycosis, , ring worm.
Not effective in aspergillosis

34. Side effects
Nausea, vomiting, headache, skin rash , diarrhea, abdominal pain , reversible alopecia.
Hepatic failure may lead to death
Highly teratogenic ( as other azoles)
Inhibit P450 cytochrome
No endocrine side effects

35. Voriconazole A broad spectrum antifungal agent Given orally or IV
High oral bioavailability
Penetrates tissues well including CSF
Inhibit P450
Used for the treatment of invasive aspergillosis & serious infections.
Reversible visual disturbances

36. Flucytosine
Synthetic pyrimidine antimetabolite (cytotoxic drug ) often given in combination with amphotericin B & itraconazole.
Systemic fungistatic

37. Mechanism of action
Converted within the fungal cell to 5- fluorouracil( Not in human cell ), that inhibits thymidylate synthetase enzyme that inhibits DNA synthesis.
( Amphotericin B increases cell permeability , allowing more 5-FC to penetrate the cell, they are synergistic).

38. Phrmacokinetics Rapidly & well absorbed orally
Widely distributed including CSF.
Mainly excreted unchanged through kidney
Half-life 3-6 hours

39. Clinical uses Severe deep fungal infections as in meningitis
Generally given with amphotericin B
For cryptococcal meningitis in AIDS patients

40. Adverse Effects Nausea, vomiting , diarrhea, severe enterocolitis
Reversible neutropenia, thrombocytopenia, bone marrow depression
Alopecia
Elevation in hepatic enzymes
(some adverse effects related to 5-Fu formed by intestinal organisms from5-FC)

41. Caspofungin
Inhibits the synthesis of fungal cell wall by inhibiting the synthesis of β(1,3)-D-glucan, leading to lysis & cell death.
Given by IV route only
Highly bound to plasma proteins
Half-life 9-11 hours
Slowly metabolized by hydrolysis & N-acetylation.
Elimination is nearly equal between the urinary & fecal routes.

42. Clinical uses Effective in aspergillus & candida infections.
Second line for those who have failed or cannot tolerate amphotericin B or itraconazole.
Adverse effects :
Nausea, vomiting
Flushing( release of histamine from mast cells)
Very expensive

43. Griseofulvin Fungistatic, has a narrow spectrum
Given orally (Absorption increases with fatty meal )
Half-life 24 hours
Taken selectively by newly formed skin & concentrated in the keratin.
Induces cytochrome P450 enzymes
Should be given for 2-6weeks for skin & hair infections to allow replacement of infected keratin by the resistant structure

44. Griseofulvin(cont.)
Inhibits fungal mitosis by interfering with microtubule function
Used to treat dermatophyte infections ( ring worm of skin, hair, nails ).
Highly effective in athlete,s foot.
Ineffective topically.
Not effective in subcutaneous or deep mycosis.
Adverse effects ;
Peripheral neuritis, mental confusion, fatigue, vertigo,GIT upset,enzyme inducer, blurred vision.
Increases alcohol intoxication.

45. Antifungal Drugs Used For Topical Fungal Infections
1. Topical azole derivatives
2. Nystatin& Amphotericin
3. Terbinafine
4. Tolnaftate
5. Naftifine
6. Griseofulvin

46. Topical Antifungal Agents
Used in superficial fungal infections , such as :
Dermatophytosis ( ring worm), candidiasis, fungal keratitis.
They are not effective in mycoses of the nails & hair or subcutaneous mycoses.
The preferred formulation for cutaneous application is cream or solution.

47. Azoles for topical use
In the form of vaginal creams, suppositories, tablets for vaginal candidiasis given once daily .

48. CLOTRIMAZOLE
Absorption is less than 0.5% from intact skin, 3-10% from vagina (its activity remains for 3 days ).
Used in dermatophytes , cutaneous candidiasis & vulvovaginal candidiasis.
Causes : Erythema, edema, , urticaria & mild vaginal burning sensation.

49. ITRACONAZOLE Effective for treatment of onychomycoses.
Should not be given in patients with ventricular dysfunction.
Evaluation of hepatic function is recommended.

50. TOLNAFTATE Effective in most cutaneous mycosis.
Ineffective against Candida.
Used in tinea pedis ( cure rate 80% ).
Used as cream, gel, powder, topical solution.
Applied twice daily.

51. NAFTIFINE Broad spectrum fungicidal . Available as cream or gel.
Effective for treatment of tinea cruris.

52. TERBINAFINE Drug of choice for treating dermatophytes (onychomycoses).
Better tolerated ,needs shorter duration of therapy.
Inhibits fungal squalene epoxidase, decreases
The synthesis of ergosterol .(Accumulation of squalene ,which is toxic to the organism causing death of fungal cell).

53. Fungicidal ,its activity is limited to candida albicans & dermatophytes.
Effective for treatment of onychomycoses
6 weeks for finger nail infection & 12 weeks for toe nail infections .
Well absorbed orally , bioavailability decreases due to first pass metabolism in liver.

54. Highly protein binding
Accumulates in skin , nails, fat.
Severely hepatotoxic, liver failure even death.
Accumulate in breast milk , should not be given to nursing mother.
GIT upset (diarrhea, dyspepsia, nausea )
Taste & visual disturbance.