Since the introduction of
amphotericin B as an
antifungal agent, the morbidity and mortality of pediatric patients with mycotic
infections have increased, primarily because of the increased immunocompromised patients. Despite the fact that
deoxycholate amphotericin B was once the primary
drug used for mycotic
infections, its administration to children older than neonates is currently controversial because of its nephrotoxic effects. Three
lipid-associated formulations have been developed and have reportedly shown similar efficacy and fewer nephrotoxic effects in adults than conventional
amphotericin B, but the conclusions from comparative studies in children evaluating the nephrotoxicity risks of the 4 agents are controversial. Nevertheless, guidelines favor liposomal or
lipid complex
amphotericin B when polyene antifungal
therapy is recommended in this age group. However, high acquisition costs often preclude their prescription in economically poor regions. Thus, physicians must consider all of these factors when determining the most cost-effective polyene antifungal treatment for their pediatric patients. This is particularly pertinent in developing countries where resources are scarce. Adjuvant
sodium supplementation has been reported to be effective in protecting kidney function in extremely low birth weight infants prescribed
deoxycholate amphotericin B. Further pharmacokinetic and pharmacodynamic studies of the
drug in children could also provide information for rational dosing regimens designed to decrease nephrotoxicity. Conventional
amphotericin B, with appropriate kidney protective measures, still plays a role in the treatment of empiric invasive mycotic
infections in most pediatric patients. Liposomal and
lipid complex
amphotericin B should be reserved for those receiving long-term nephrotoxic agents or with altered renal function or disease. Antifungal susceptibility, renal compromise and the clinical status of the patient should determine treatment for culture-proven
infections. Under the current cost limitations, undertaking and evaluating low-cost, kidney-sparing,
deoxycholate amphotericin B treatments for children should be a primary concern.