Name of the Anti-Fungal Drugs
- Ketoconazole
- Clotrimazole
- Miconazole nitrate
- Griseofulvin
- Nystatin
| Ketoconazole |
| Availability: Cream: 2% Shampoo: 1%, 2% Tablets: 200 mg |
| Indication & dosage Blastomycosis; chronic mucocutaneous candidiasis; oral thrush; candiduria; coccidioidomycosis; histoplasmosis; chromomycosis; paracoccidioidomycosis; mucocutaneous or vaginal candidiasis Adults: 200 to 400 mg P.O. daily Children ages 2 and older: 3.3 to 6.6 mg/kg P.O. as a single daily dose. Duration depends on infection: for candidiasis, 1 to 2 weeks; other systemic mycoses, 6 months; recalcitrant dermatophyte infections involving glabrous skin, 4 weeks. Chronic mucocutaneous candidiasis requires maintenance therapy. |
| Scaling caused by dandruff or seborrheic dermatitis Adults: 2% shampoo applied topically twice weekly for 4 weeks, then as needed to control symptoms, with at least 3 days between applications; or 1% shampoo applied topically q 3 to 4 days for up to 8 weeks, then as needed to control dandruff |
| Tinea corporis; tinea cruris; tinea versicolor; tinea pedis, cutaneous candidiasis Adults: 2% cream applied topically to affected areas daily for 2 weeks (except for tinea pedis, which may require 6 weeks of therapy) |
| Mechanism of Action : Ketoconazole impairs the synthesis of ergosterol , which is a vital component of fungal cell membranes |
| Contraindications : Hypersensitivity to drug or its components Concurrent oral astemizole, cisapride, triazolam, or terfenadine therapy |
Administration:
- Apply cream to damp skin of affected area and wide surrounding area.
- To use shampoo, wet hair, then apply shampoo and massage into scalp for 1 minute. Leave on for 5 minutes before rinsing. Rinse and repeat, this time leaving shampoo on scalp for 3 minutes before rinsing.
- Don’t apply shampoo to broken or inflamed skin.
- In achlorhydria, dissolve 200-mg tablet in 4 ml of 0.2N hydrochloric acid solution.
- Withhold antacids for at least 2 hours after giving oral ketoconazole.
- Don’t give concurrently with cisapride, available in U.S. for compassionate use only. (Astemizole and terfenadine are not available in U.S.)
Metabolism & Elimination:
Partially metabolized in liver via CYP3A4 to inactive compounds
Half-life: Biphasic: initial, 2 hr; terminal ,8 hr
Excretion: Feces (57%), urine (13%)
Precautions:
renal or hepatic disease, achlorhydria
pregnant or breastfeeding patients
children younger than age 2.
Adverse reactions
CNS: headache, nervousness, dizziness, drowsiness, severe depression, suicidal ideation
EENT: photophobia
GI: nausea, vomiting, diarrhoea, abdominal pain, anorexia
GU: erectile dysfunction, gynecomastia
Hematologic: purpura, haemolytic anaemia, thrombocytopenia, leukopenia
Hepatic: hepatotoxicity
Metabolic: hyperlipidaemia
Skin: pruritus, rash, dermatitis, urticaria, severe irritation, stinging, alopecia, abnormal hair texture, scalp pustules, oily skin, dry hair and scalp
Other: fever, chills, allergic reaction
Patient monitoring
- Assess for suicidal ideation and signs and symptoms of depression.
- Monitor for evidence of hepatotoxicity, such as nausea, fatigue, jaundice, dark urine, and pale stools.
- With long-term therapy, stay alert for adrenal crisis.
Patient teaching
- Advise patient to watch for signs and symptoms of depression and to immediately report suicidal thoughts.
- Teach patient to recognize and immediately report signs and symptoms of hepatotoxicity, such as unusual tiredness or yellowing of skin or eyes.
- Advise patient not to take antacids for at least 2 hours after oral ketoconazole
- Instruct patient to apply cream to damp skin of affected area and wide surrounding area.
- Tell patient to wet hair before applying shampoo and to massage into scalp for 1 minute; then leave on for 5 minutes before rinsing off. Tell him to shampoo again, leaving it on for 3 minutes this time before rinsing.
- Caution patient not to apply shampoo to broken or inflamed skin.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, and herbs mentioned above.
| Clotrimazole |
| Availability: Topical cream/ointment/solution 1% Vaginal cream 1% ,2% Cutaneous Candidiasis/ Dermatophytosis Adult dosage Apply to affected area every 12 hours |
| Indication & dosage ØVaginal candidiasis : Adult dosage Cream (1%): Insert 1 applicatorful daily, preferably at bedtime, for 7-14 days Cream (2%): Insert 1 applicatorful daily, preferably at bedtime, for 3 consecutive days |
| Superficial Dermatologic Infection : Adult dosage Apply to affected area every 12 hours for 7 consecutive days |
| Mechanism of Action : Antifungal activity Alters cell membrane permeability, apparently by binding with phospholipids in the fungal cell membrane, causing essential intracellular elements to leak |
| Contraindications : Hypersensitivity to clotrimazole or components |
Metabolism & Elimination:
Absorption
Negligible through intact skin (3-10% absorbed with intravaginal dose)
Time to peak: ~24 hr (vaginal cream)
Precautions:
- Avoid contact with eyes
- Some dosage forms contain benzyl alcohol; large amounts of benzyl alcohol have been associated with gasping syndrome (potentially fatal) in neonates
- Not for use by patients who have never had a vaginal infection diagnosed by a doctor
- Not for use with tampons, douches, spermicides, or other vaginal products
- Condoms and diagrams may damage and fail to prevent pregnancy or sexually transmitted disease
- Not for use when having vaginal intercourse
- May cause mild increase in vaginal burning, itching or irritation
- Patient should ask doctor if symptoms do not get better in 3 days, symptoms last more than 7 days, or experience rash, abdominal pain, fever, chills, nausea, vomiting, or a foul-smelling vagina discharge
Adverse Reactions/Side Effects
Local: burning, itching, local hypersensitivity reactions, redness, stinging.
Nursing consideration
- Assess for the mentioned cautions and contraindications (e.g. known history of allergy to antifungals, liver and kidney dysfunction, pregnancy and lactation, etc.) to prevent any untoward complications.
- Perform a thorough physical assessment (other medications taken, orientation and reflexes, skin color and lesions, etc.) to establish baseline data before drug therapy begins, to determine effectiveness of therapy, and to evaluate for occurrence of any adverse effects associated with drug therapy.
- Obtain a culture of the infected area to make an accurate determination of the type and responsiveness of the fungus.
- Evaluate renal and hepatic function tests and complete blood count to determine baseline function of these organs and to assess possible toxicity during drug therapy.
| Miconazole nitrate |
| Availability: Cream: 20mg/g (2%) Ointment: 2.5mg/g (0.25%) with Zinc Oxide 150mg/g (15%) Oral Gel: 20mg/g (2%) |
| Mechanism of Action Azole antifungal agent; inhibits enzyme cytochrome P450 14-alpha-demethylase resulting in ergosterol synthesis inhibition |
| Indication & dosage Candidiasis of nipple Topical (cream): Apply cream to nipple after each feed. Removal is not indicated as this may cause further nipple trauma and the medication is compatible with breastfeeding (poor oral absorption).Cutaneous candidiasis Topical (Cream): Apply cream to the affected area and surrounding skin TWICE daily. Continue treatment until the lesions have completely healed and for a further TWO weeks. Oropharyngeal candidiasis Topical/Oral (Oral gel): Adults: HALF a teaspoon (2.5mL) topically (then swallowed) using the measure provided FOUR times daily. Continue for 7-14 days. |
| Precautions : Nail and scalp infections (may require additional systemic therapy) OB: Lactation: Safety not established. |
| Contraindications : •Hypersensitivity to active ingredients, additives, preservatives, or bases •Some products contain alcohol or bisulfites and should be avoided in patients with known intolerance. |
| Metabolism & Elimination: Excretion: Feces, urine Metabolism: CYP3A4 |
Patient teaching
- Instruct patient to apply medication as directed for full course of therapy, even if feeling better. Emphasize the importance of avoiding the eyes.
- Caution patient that some products may stain fabric, skin, or hair. Check label information. Fabrics stained from cream or lotion can usually be cleaned by handwashing with soap and warm water; stains from ointments can usually be removed with standard cleaning fluids.
- Patients with athlete’s foot should be taught to wear well-fitting, ventilated shoes, to wash affected areas thoroughly, and to change shoes and socks at least once a day.
- Advise patient to report increased skin irritation or lack of response to therapy to health care professional.
Adverse Reactions/Side Effects
Local: burning, itching, local hypersensitivity reactions, redness, stinging
Administration
Best after a meal or drink, keep it in your mouth for as long as possible before swallowing. Continue use for several days after symptoms disappear. If you are giving this to someone who can’t swallow properly, be careful to apply it at the front of the mouth in small amounts so that they don’t choke. Apply gel to dentures after cleaning and leave overnight.
| Griseofulvin |
| Availability: oral suspension, microsize,125mg/5mL (generic):tablet, microsize ,500mg (generic):tablet, ultramicrosize,125mg (generic),250mg (generic) |
| Mechanism of Action Fungistatic; deposited in keratin precursor cells and is tightly bound to new keratin, and this increases resistance to fungal invasion |
| Indication & dosage Tinea capitis : adult :0.5-1 g daily in single or divided dose for 4-6 weeks Tinea corporis : adult :0.5-1 g daily in single or divided dose for 2-4 weeks Tinea unguium : adult :0.5-1 g daily in single or divided dose for 4-8 weeks Child :10-15 mg/kg daily |
| Contraindications :sever hepatic disease, pregnancy , porphyria , monilial infection , systemic lupus erythematosus |
| Metabolism & Elimination: Metabolism:Extensively metabolized by liver; hepatic CYP3A4 induced Elimination:Half-life: 9-22 hr Excretion: Urine (<1% as unchanged drug), feces, perspiration |
| Precautions : •Severe skin reactions (Stevens-Johnson syndrome, toxic epidermal necrolysis) and erythema multiforme were reported, some resulting in hospitalization or death; discontinue if severe skin reaction occurs. •Elevations in AST, ALT, bilirubin, and jaundice were reported, some resulting in hospitalization or death; discontinue if jaundice occurs. •Patients on prolonged therapy with any potent medication should be under close observation; periodic monitoring of organ system function, including renal, hepatic and hematopoietic, should be done. |
| Nystatin |
| Availability: Cream: 100,000 units/g Ointment: 100,000 units/g Powder: 100,000 units/g Suspension: 100,000 units/ml Tablets: 500,000 units Troches: 200,000 units Vaginal tablets: 100,000 units |
| Indication & dosage ➣ Candidiasis (topical use) Adults and children: Apply cream, ointment, or powder two or three times daily until healing is complete. |
| ➣ Oral candidiasis Adults: 400,000 to 600,000 units (suspension) P.O. q.i.d. Have patient gargle and then swallow half of dose in each side of mouth. Infants: 200,000 units (suspension) P.O. q.i.d. Use half of dose in each side of mouth. Newborn and premature infants: 100,000 units (suspension) P.O. q.i.d. Use half of dose in each side of mouth. |
| ➣ GI infections Adults: 500,000 to 1 million units (one to two tablets) P.O. t.i.d. Continue for 48 hours after desired response occurs. |
| ➣ Vaginal candidiasis Adults: 100,000 units (one vaginal tablet) intravaginally daily for 2 weeks, or 100,000- to 500,000-unit applicatorful (cream) intravaginally once or twice daily for 2 weeks |
| Mechanism of Action Binds to sterols in fungal cell membranes, impairing membrane integrity. Cells lose intracellular potassium and other cellular contents and, eventually, die. |
| Administration : ● Give oral suspension by placing half of dose in each side of patient’s mouth. Instruct patient to hold suspension in mouth, swish it around, or gargle for several minutes before swallowing it. ● To prepare oral solution from powder, add one-eighth teaspoon to 120 ml of water and stir well. Give immediately. ● Advise patient to let troche dissolve slowly and completely in mouth. Tell her not to chew or swallow it whole. ● Know that nystatin vaginal tablets can be given orally to treat oral candidiasis. ● To apply cream, ointment, or powder, gently and thoroughly massage preparation into skin. ● Use applicator provided for vaginal administration. |
Contraindications
- Hypersensitivity to drug or its components
Metabolism & Elimination:
Absorption
- Poor PO absorption
Onset: Symptom relief for oral candidiasis 24-72 hr
Elimination
Excretion: Feces (as unchanged drug)
Precautions:
- renal or hepatic disease, achlorhydria
- pregnant or breastfeeding patients
- children younger than age 2.
Nursing Considerations
- Prepare nystatin powder for oral suspension for each dose; it has no preservatives.
- Gently rub nystatin cream or ointment into skin at affected area. Keep area dry and avoid occlusive dressings.
- Don’t get topical form in patient’s eyes.
- When treating candidal infection of feet, dust patient’s shoes, socks, and feet.
- For vaginal form, use applicator supplied by manufacturer.
Adverse reactions
GI: nausea, vomiting, diarrhoea, distress, oral irritation
GU: vulvovaginal irritation (with intravaginal form)
Skin: pruritus, rash
Patient monitoring
- If patient takes oral tablets, inspect oral mucous membranes for irritation.
- With topical use, monitor affected area for increase in redness, swelling, or irritation.
Patient teaching
- Advise patient to continue taking for at least 48 hours after symptoms resolve.
- Instruct patient to let lozenge dissolve slowly in mouth. Tell her not to chew or swallow it.
- If patient misses a dose, tell her to take dose as soon as possible and then resume her regular dosing schedule.
- Inform patient that diabetes mellitus, reinfection by sexual partner, tight-fitting pantyhose, and use of antibiotics, hormonal contraceptives, or corticosteroids predispose her to vaginal infection. Urge her to wear cotton underwear.
- Tell female patient to practice careful hygiene in affected areas.
- Instruct patient using vaginal tablets to wash applicator thoroughly after each use.
- Tell patient to continue therapy during menstruation.
- As appropriate, review all significant adverse reactions and interactions, especially those related to the drugs and behaviors mentioned above.
REFERENCES
- Robert Kizior, Keith Hodgson, Saunders Nursing Drug handbook,1st edition 2024, Elsevier Publications. ISBN-9780443116070
- McGraw Hill- Drug Handbook, Seventh Edition, 2013, McGraw Hill Education Publications,9780071799430.
- April Hazard, Cynthia Sanoski, Davi’s Drug Guide for Nurses -Sixteenth Edition 2019, FA Davis Company Publications,9780803669451.
- Jones and Bartlet, Pharmacology for Nurses, Second Edition, 2020, Jones and Bartlet Learning Publications, ISBN 9781284141986.
- Nursebro.com, Search – Nursebro
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