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Polyene Antifungal — Invasive Fungal Infections (Aspergillosis / Cryptococcosis / Candida) Pregnancy: Use with caution — amphotericin B conventional considered relatively safer than azoles in pregnancy; liposomal preferred if required

Amphotericin B (Liposomal)

Brand names: AmBisome

Adult dose

Dose: Invasive fungal infection: 3 mg/kg IV once daily; Empirical febrile neutropenia: 3 mg/kg IV once daily; Cryptococcal meningitis: 3–4 mg/kg IV once daily; Visceral leishmaniasis: 3–4 mg/kg IV on days 1–5, 14, 21
Route: Intravenous infusion over 30–60 minutes
Frequency: Once daily
Max: 5 mg/kg/day (higher doses used in specialist protocols)
Liposomal formulation (AmBisome) preferred over conventional amphotericin B deoxycholate — significantly lower nephrotoxicity. Test dose (1 mg over 10 minutes) before first infusion then observe 30 minutes. Pre-medicate with paracetamol and chlorphenamine to reduce infusion reactions. Protect from light. Flush line with 5% dextrose only — incompatible with saline.

Paediatric dose

Dose: 3 mg/kg mg/kg
Route: IV
Frequency: Once daily
Max: 5 mg/kg/day
BNFc: same dosing as adults on per-kg basis; used in neonatal candidiasis, invasive Aspergillus in immunocompromised children

Dose adjustments

Renal

Liposomal formulation: no dose reduction required even in renal impairment — key advantage over conventional amphotericin; monitor closely and hydrate well

Hepatic

No dose adjustment required

Paediatric weight-based calculator

BNFc: same dosing as adults on per-kg basis; used in neonatal candidiasis, invasive Aspergillus in immunocompromised children

Clinical pearls

  • Liposomal vs conventional: liposomal AmBisome delivers amphotericin encapsulated in liposomes — preferentially accumulates in macrophages (where fungi reside); much lower renal tubular toxicity; same efficacy but markedly safer
  • Cryptococcal meningitis: WHO recommended induction: liposomal amphotericin 3 mg/kg + flucytosine 100 mg/kg/day × 2 weeks → fluconazole consolidation; flucytosine synergism critical for sterilising CSF faster and reducing relapse
  • Electrolyte wasting: potassium and magnesium replacement required throughout — aggressive IV/oral supplementation; hypomagnesaemia worsens hypokalaemia (correcting K without Mg fails)
  • Saline incompatibility: must flush line with 5% dextrose — saline causes aggregation of liposomes; label the line clearly

Contraindications

  • Hypersensitivity to amphotericin B or components of liposomal formulation
  • Conventional deoxycholate amphotericin (avoid in significant renal impairment — use liposomal)

Side effects

  • Infusion reactions (fever, rigors, nausea, vomiting — premidicate)
  • Nephrotoxicity (significantly less with liposomal vs conventional)
  • Hypokalaemia (renal potassium wasting)
  • Hypomagnesaemia
  • Anaemia
  • Hepatotoxicity
  • Phlebitis (peripheral lines)

Interactions

  • Aminoglycosides — additive nephrotoxicity
  • Ciclosporin/tacrolimus — additive nephrotoxicity
  • Corticosteroids — potentiate hypokalaemia
  • Digoxin — hypokalaemia increases toxicity
  • Flucytosine — synergistic for cryptococcal meningitis (combination therapy)

Monitoring

  • Renal function and electrolytes daily (K, Mg — replace aggressively)
  • LFTs
  • FBC (anaemia)
  • Temperature and vital signs during infusion
  • Therapeutic drug monitoring not routine but may be considered

Reference: BNFc; BNF 90; ECMM/ISHAM Cryptococcal Meningitis Guidelines; ESCMID/ECMM Aspergillosis Guidelines; WHO HIV/Cryptococcosis Guidelines 2022. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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