Treatment approaches for FE
Approach | Agent/Intervention | Regimen/Indications | Key considerations | References |
---|---|---|---|---|
First-line antifungals | Liposomal amphotericin B (LAmB) | 3–5 mg/kg/day IV; ± flucytosine (25 mg/kg Q6h) for synergy | Nephrotoxic; monitor creatinine/electrolytes | [48, 49] |
Echinocandins (caspofungin, micafungin) | Preferred for Candida; alternative to LAmB in renal impairment | Less effective against C. parapsilosis; biofilm penetration is limited | [49, 79] | |
Azoles (voriconazole, posaconazole) | Consolidation: voriconazole (Aspergillus); fluconazole (Candida, susceptible strains) | TDM required; hepatotoxic/QT prolongation; drug interactions (CYP450) | [51, 55] | |
Surgical intervention | Valve replacement/device removal | Indications: heart failure, abscess, vegetations > 10 mm, persistent fungemia, embolic risk | Reduces mortality by 80% vs. medical therapy alone; perform early (within 1–2 weeks) | [5, 23, 63, 64] |
Pathogen-specific | C. auris | Rezafungin (once-weekly echinocandin); combination therapy (LAmB + echinocandin) | Intrinsic multidrug resistance | [69, 77] |
Aspergillus | Voriconazole (primary); LAmB if contraindicated | Galactomannan/PCR guides diagnosis | [15, 55] | |
Trichosporon/Lomentospora | LAmB + voriconazole (echinocandin-resistant) | Salvage therapy | [57, 59] | |
Novel therapies | Rezafungin | Long-acting echinocandin; weekly IV dosing | Limited FE data; active against resistant Candida | [69, 70] |
Ibrexafungerp | Oral triterpenoid; biofilm penetration; broad activity | Pending IE trials | [71] | |
NDV-3A vaccine (Als3p target) | Preclinical; enhances host immunity against C. auris | Not yet human-tested | [72] |
FE: fungal endocarditis; IE: infective endocarditis; PCR: polymerase chain reaction; TDM: therapeutic drug monitoring; C. auris: Candida auris; C. parapsilosis: Candida parapsilosis
I would like to acknowledge Krupa Sara Thomas for her valuable assistance in reviewing and going through the manuscript.
SE: Conceptualization, Investigation, Writing—original draft, Writing—review & editing. The author has read and approved the submitted version.
The author declares that there are no conflicts of interest.
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