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Antifungal — Polyene (Ophthalmic Compounded / Systemic IV) Pregnancy: Use systemic amphotericin only for life-threatening fungal infection — benefits must outweigh risks

Amphotericin B (Ophthalmic — Severe Fungal Keratitis/Endophthalmitis)

Brand names: AmBisome (systemic); Amphotericin 0.15% eye drops — compounded

Adult dose

Dose: Topical: 1 drop of 0.15% every 30 minutes–2 hours (severe keratitis); Systemic: 1–1.5 mg/kg/day liposomal IV (AmBisome) for fungal endophthalmitis
Route: Topical (compounded) or Intravenous (liposomal — systemic)
Frequency: Topical: 30 minutes to hourly; Systemic: once daily IV
Max: Topical: as frequently as required. Systemic: 5 mg/kg/day (liposomal)
Topical amphotericin drops are compounded (0.075–0.3% solution); not commercially available. Systemic: use liposomal amphotericin B (AmBisome) not conventional deoxycholate — far lower nephrotoxicity. Intravitreal amphotericin (5 mcg in 0.1 mL) used for Candida endophthalmitis.

Paediatric dose

Dose: 3–5 mg/kg
Route: IV (liposomal)
Frequency: Once daily
Max: 5 mg/kg/day
Paediatric fungal endophthalmitis — liposomal amphotericin under specialist infectious disease guidance; weight-based dosing essential

Dose adjustments

Renal

Liposomal amphotericin: preferred in renal impairment — far less nephrotoxic than conventional amphotericin; monitor creatinine. Conventional deoxycholate: causes nephrotoxicity in virtually all patients — avoid

Hepatic

No dose adjustment required

Paediatric weight-based calculator

Paediatric fungal endophthalmitis — liposomal amphotericin under specialist infectious disease guidance; weight-based dosing essential

Clinical pearls

  • Liposomal vs conventional amphotericin: conventional amphotericin B deoxycholate causes nephrotoxicity in virtually ALL patients (acute tubular necrosis, distal RTA, hypokalaemia); liposomal formulation (AmBisome) dramatically reduces nephrotoxicity while maintaining antifungal efficacy — standard of care in UK for systemic antifungal therapy
  • Infusion reactions: fever, rigors, and chills occur with systemic amphotericin — premedicating with paracetamol, antihistamine, and sometimes hydrocortisone reduces severity; reactions are less common with liposomal formulation
  • Candida endophthalmitis (post-candida bloodstream infection): all patients with candidaemia should have a formal ophthalmology examination — chorioretinal Candida lesions affect management (systemic antifungal duration must be extended; intravitreal amphotericin if vitritis present)
  • Topical 0.15% drops for Aspergillus keratitis: amphotericin B has excellent activity against Aspergillus — alternative to natamycin in centres with compounding pharmacy availability
  • Electrolyte monitoring: systemic amphotericin causes potassium and magnesium wasting through tubular toxicity — daily electrolyte monitoring and aggressive replacement essential; hypokalaemia can cause arrhythmias

Contraindications

  • Conventional amphotericin B deoxycholate for systemic use when liposomal is available — excess nephrotoxicity
  • Hypersensitivity to amphotericin

Side effects

  • Systemic: nephrotoxicity — conventional form causes renal tubular acidosis, hypokalaemia, hypomagnesaemia; liposomal (AmBisome) substantially reduces this risk
  • Infusion-related reactions — fever, rigors, chills, nausea, hypotension; premedicate with paracetamol + antihistamine ± hydrocortisone
  • Hypokalaemia and hypomagnesaemia — electrolyte replacement required
  • Topical: corneal irritation, burning

Interactions

  • Nephrotoxic drugs (aminoglycosides, ciclosporin, tacrolimus) — additive nephrotoxicity with systemic amphotericin; avoid concurrent use
  • Corticosteroids — hypokalaemia risk with combination; monitor electrolytes
  • Flucytosine — synergistic antifungal combination for Candida endophthalmitis (5FC + amphotericin)

Monitoring

  • Renal function (eGFR, creatinine) daily (systemic)
  • Electrolytes (K+, Mg2+) daily (systemic)
  • LFTs
  • Ophthalmology assessment for chorioretinal involvement
  • Culture results — sensitivity-guided de-escalation

Reference: BNFc; BNF 90; IDSA Candidiasis Guidelines 2016; ECMM/ISHAM Fungal Keratitis Guidelines; RCOphth Guidelines; SPC AmBisome. Verify against your local formulary and the latest BNF before prescribing.

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Curated clinical cross-links plus same-class fallbacks.

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