Use of Topical Amphotericin for Adjunctive Management of Fungal Infections in Acute Burn Injuries

Introduction: Patients with burn injuries are at a high risk of developing invasive fungal infections that can result in increased morbidity and mortality. Systemic agents used to treat fungal infections, such as voriconazole and amphotericin B (AmB), are associated with treatment-limiting adverse effects including infusion-reactions, nephrotoxicity, hepatotoxicity, and electrolyte abnormalities. Effective use of these agents can also be challenging, as physiological changes associated with burn injuries can significantly impact fluid balance, renal function and drug pharmacokinetics. Topical application of AmB, as alternative or adjunctive therapy, may facilitate localized treatment while minimizing adverse reactions.


Description: We present a case series of three patients who received topical AmB as adjunctive treatment for invasive fungal infections in the setting of acute burn injuries. Patient A was a 30 year-old male admitted with a 70% total body surface area (TBSA) flame burn. The patient developed an invasive Aspergillus wound infection and initiated on voriconazole. Due to challenges achieving therapeutic voriconazole levels, as well as slow wound improvement, topical conventional AmB was added to therapy. Patient B was a 49 year-old male admitted with a 5% TBSA flame burn complicated by a Rhizopus tissue infection. The patient was treated with IV liposomal AmB with the subsequent addition of topical liposomal AmB. Patient C was a 62 year-old male admitted with a 36% TBSA flame burn complicated by an Aspergillus wound infection. He was simultaneously initiated on voriconazole and topical conventional AmB. Topical AmB doses were compounded by the pharmacy and were formulated to a final concentration of 24mcg/mL. All three patients experienced successful treatment with combination therapy without adverse effects.


Discussion: Topical AmB, both liposomal and conventional formulations, was used successfully as adjunctive treatment in the management of burn-related invasive fungal infections. Given the challenges encountered in treating these infections, adjunctive topical therapy may optimize drug delivery and treatment.