5. Fungal infections Flashcards
What is chronic hyperplastic candidosis potentially?
Premalignant and therefore refer patients with this condition for specialist treatment.
Why is compliance of nystatin poor?
Nystatin, the topical antifungal, is effective against superficial fungal infections but compliance is poor because of its unpleasant taste.
Thus miconazole or fluconazole or the systemically absorbed fluconazole are preferred unless contraindicated.
What drugs does fluconazole interact with?
Many drugs, including warfarin and statins, and therefore do not give fluconazole to patients taking these drugs.
In addition, avoid use of miconazole, a topical azole antifungal agent, in such patients because sufficient drug is absorbed to cause similar interactions.
Which groups of patients are predisposed to pseudomembranous candidosis and erythematous candidosis? (5)
- Pts taking inhaled corticosteroids
- Pts taking cytotoxics or broad-spectrum antibiotics
- Diabetic patients
- Pts with nutritional deficiencies
- Pts with serious systemic disease associated with reduced immunity such as leukaemia, other malignancies and HIV infection.
What should you do if a pt does not respond to appropriate local measures and a course of drug treatment, or there is no identifiable cause?
Refer pt to a specialist or the patient’s general medical practitioner for further investigation
What treatment is likely to be needed for fungal infections in immunocompromised patients with serious systemic disease?
They are likely to need intravenous systemic treatment: therefore, refer such patients to a specialist or the patient’s GMP.
What local measure can be advised to a patient with prescribed inhaled corticosteroids for fungal infections?
Advise patients who use a corticosteroid inhaler to rinse their mouth with water or to brush their teeth immediately after using the inhaler.
What drug treatments is appropriate for pseudomembranous candidosis and erythema candidosis? (first line) (2)
- Fluconazole capsules, 50mg.
1 capsule/day for 7 days.
(7 capsules total). - Miconazole oromucosal gel, 20mg/g.
Apply a pea-sized amount after food four times daily for 7 days.
If fluconazole and miconazole are contraindicated, what can be prescribed for pseudomembranous/erythematous candidiasis?
Nystatin oral suspension, 100,000 units/ml.
1ml after food four times daily for 7 days.
What is the maximum number of days fluconazole can be administered for?
14 days for the treatment of oropharyngeal candidosis.
In which patients should you not prescribe fluconazole?
Patients taking warfarin or statins
What advise should be given when prescribing miconazole oromucosal gel for fungal infections?
Advise patient to continue for 7 days after lesions have healed.
In which patients should you not prescribe miconazole oromucosal gel?
Patients taking warfarin or statins
What advise should you give to patients taking nystatin oral suspension 100,000 units/ml?
Advise pt to rinse suspension around mouth and then retain suspension near lesion for 5 minutes before swallowing.
Advise pt to continue use for 48 hours after lesions have healed.
How can you treat denture stomatitis broadly speaking?
Denture stomatitis can be treated effectively by local measures:
- brush the palate daily to treat the condition.
- clean their dentures thoroughly (by soaking in chlorhexidine mouthwash or sodium hypochlorite for 15 minutes twice daily; note that hypochlorite should only be used for acrylic dentures)
- leave their dentures. out as often as possible during the treatment period.
However, antifungal agents can be used as an adjunct to these local measures, particularly to reduce palatal inflammation before taking impressions for new dentures. Chlorhexidine mouthwash is also effective against fungal infections.
What local measures can be advised for denture stomatitis?
- Brush the palate daily to treat the condition.
- Clean dentures thoroughly (by soaking then in chlorhexidine mouthwash or sodium hypochlorite for 15 minutes twice daily; note that sodium hypochlorite can only be used for acrylic dentures)
- Leave their dentures out as often as possible during the treatment period.
– If dentures themselves are identified as contributing to the problem, ensure the dentures are adjusted or new denture are made to avoid the problem recurring.
If drug treatment is required for denture stomatitis, what can be prescribed?
Fluconazole capsules, 50mg. 1 capsule/day for 7 days. (total 7 capsules)
or
Miconazole oromucosal gel 20mg/g. Apply pea-sized amount to fitting surface of upper denture after food 4x/day. 7-day regimen.
If fluconazole and miconazole are contraindicated for denture stomatitis, what else could be prescribed?
Nystatin oral suspension 100,000 units/ml. 1ml after food 4x/day for 7 days.
Advise pt to rinse suspension around mouth and then retain suspension near lesion for 5 minutes before swallowing.
Advise pt to continue use for 48 hours after lesions have healed.
Who does angular cheilitis tend to occur in?
Angular cheilitis in denture-wearing patients is usually caused by infection with Candida spp. and there is an associated denture stomatitis that should be treated concurrently.
In those without dentures, angulus cheilitis is more likely to be caused by infection with streptococcus spp. or staphylococcus spp.
What organisms tend to cause angular cheilitis in which populations?
Angular cheilitis in denture-wearing pts is usually caused by infection with Candida spp.
In those without dentures, angular cheilitis is more likely to be caused by infection with Streptococcus spp. or Staphylococcus spp.
What cream is appropriate for angular cheilitis?
Miconazole cream is effective against Candida and Gram-positive cocci and is therefore appropriate to use for all patients, except those taking warfarin or statins.
When angular cheilitis is clearly bacterial in nature, what ointment can be prescribed?
Sodium fusidate (fusidic acid) ointment can be used.
Unresponsive cases of angular cheilitis can be treated with what?
Unresponsive cases can be treated with miconazole and hydrocortisone cream or ointment, except those patients taking warfarin or statins.
What might a lack of clinical response to treatment of angular cheilitis indicate?
Predisposing factors such as a concurrent haematinic deficiency or diabetes.
Refer such cases to a specialist or the patient’s general medical practitioner.
What should you do if dentures are contributing to angular cheilitis?
Ensure the dentures are adjusted or new dentures are made to avoid the problem recurring.
What is an appropriate prescription for angular cheilitis?
- Miconazole cream, 2%.
Apply to angles of mouth twice daily.
or
- Sodium fusidate ointment, 2%. apply to angles of mouth 4 times daily.
What is an appropriate prescription for unresponsive cases of angular cheilitis?
- Miconazole (2%) and hydrocortisone (1%) cream. Apply to angles of mouth twice daily.
- Miconazole (2%) and hydrocortisone (1%) ointment. Apply to angles of mouth twice daily.
Creams are normally use don wet surfaces whereas ointments are normally used on dry surfaces.
What is an appropriate prescription for angular cheilitis of miconazole cream?
Miconazole cream 2%
Apply to angles of mouth twice daily.
Advise pt to continue use for 10 days after lesions have healed.
In which patients should you not prescribe miconazole cream 2%?
Pts taking warfarin or statins
How can you prescribe sodium fusidate ointment 2% for angular cheilitis?
Sodium fusidate ointment 2%. Apply to angles of mouth four times daily.
To avoid development of resistance, do not prescribe sodium fusidate for longer than 10 days.
How can you prescribe miconazole 2% and hydrocortisone 1% cream/ointment for unresponsive angular cheilitis?
Miconazole (2%) and Hydrocortisone (1%) cream/ointment.
Apply to angles of mouth twice daily.
NB: advise patient to continue use for a maximum of 7 days.
Do not prescribe miconazole for patients taking warfarin or statins.
