Antifungals

Question 1

Anidulafungin (Eraxis)

Answer 1

IV only
Echinocandin
Candidemia, esophagial candida
No know DDI
Monitor: liver enzymes, histamine related reactions
Preg C

Question 2

Caspofungin (Cancidas)

Answer 2

IV
Echinocandin
Aspergillosis, candidiasis
In positive culture, treat for 14 more days.
In neutropenic pts, treat for 7 days post s/s of infection.
DDI (avoid) - cyclosporine (increased liver enzymes)
SE: hypotension, tachy, fever, chills, headache
Preg C

Question 3

Micafungin (Mycamine)

Answer 3

IV
Echinocandin
Candidemia, esophageal candida, SCT prophylaxis
SE: low K, Mg, fever, HA, thrombocytopenia, phlebitis

Question 4

Why is the Echinocandin class so limited in uses?

Answer 4

All IV

Question 5

Blastomycosis

Answer 5

Geo: East of Mississippi River and Central America
Inflammatory lung disease/pneumo –> skin/bone
Culture in Sabouraud’s Agar
Tx: Amphotericin B or Itraconazole

Question 6

Coccidioidomycosis

Answer 6

Geo: SW US, California (San Joaquin Valley)
"valley fever" or "desert bumps"
pneumonia, meningitis --> skin/bone
see spherule filled with endospheres
Tx: Itraconazole or fluconazole

Question 7

Histoplasmosis

Answer 7

Geo: Mississippi and Ohio River Valley
pneumonia (macrophages filled with histoplasma)
Associated with bat/bird droppings
Tx: Amphotericin B or Itraconazole

Question 8

Invasive Aspergillosis

Answer 8

In immunocompromised patients
“fungal ball”
see 45 degree angle branching septae and hyphae
Tx: voriconazole (DOC)

Question 9

Candida albicans

Answer 9

esophageal candida - immunocompromised
vulvovaginitis (high pH, diabetes, abx use)
Tx: most antifungals

Question 10

Cryptococcus neoformans

Answer 10

cryptococcal meningitis in immuno compromised pts
Cultured in Sabouraud’s agar
“soap bubble” lesions in brain
Tx: Amphotericin B + flucytosine x 14 days, then fluconazole x 6 months

Question 11

pneumocystis jirveci

Answer 11

immunocompromised pts - diffuse interstitial pneumonia
mainly in HIV CD4,200
Tx: TMP/SMX

Question 12

sporotrichosis

Answer 12

Rose bush thorns
local pustule/ulcer
Tx: itraconazole

Question 13

Amphotericin (Fungizone) MOA

Answer 13

binds to ergosterol in cell wall, increases permeability and lysis. Makes a hole.

Question 14

Amphotericin (Fungizone)

Answer 14

PO/IV/Top
Ergosterol Inhibitor: Polyene
All fungi covered
SE: infusion reaction (test dose, premedicate with NSAID/benadryl), nephrotoxic (pre/post hydrate and be careful if giving with other nephrotoxic abx)

Question 15

Nystatin

Answer 15

PO/Top
Ergosterol Inhibitor: Polyene
swish and swallow or troche (dissolve over 15-20 min)
does not absorb, poor bioavailability
frequency of dosing (QID) is biggest issue

Question 16

Terbinafine (Lamisil) MOA

Answer 16

inhibits ergosterol synthesis through inhibition of squalene epoxidase, increases permeability, lysis

Question 17

Terbinafine (Lamisil)

Answer 17

Ergosterol Inhibitor: Synthetic Allylamine
onchomycosis, ringworm, jock itch
SE: GI, hepatotoxicity
adjust dose CrCl<50

Question 18

Fungal Sterol Inhibitors (-azoles) MOA

Answer 18

inhibits conversion of lanosterol to ergosterol. Loss of ergosterol decreases ability to grow/replicate.

Question 19

Fluconazole (Diflucan)

Answer 19

PO
Fungal Sterol Inhibitor: Triazole
oral candida, eso candida, prophylaxis BMT, vag candida, crytococcal meningitis
decrease dose by 50% if CrCl<50
CYP inhibitor: 2C8/9 (strong)
Good CNS penetration

Question 20

Itraconazole (Sporanox)

Answer 20

PO (+food/acid)
Fungal Sterol Inhibitor: Triazole
aspergillosis, histo/blasto, onycho
3A4 inhibitor (major)
SE: hepatotoxicity and can worsen CHF

Question 21

Voriconazole (Vfend)

Answer 21

IV/PO
Fungal Sterol Inhibitor: Triazole
aspergillosis, candidia
If on Dilantin or efavirenz, increase dose
adjust dose CrCl<50
Inhib: 3A4 (strong), 2C19, 2C9 (mod)
SE: melanoma (photosensitivity)
Counsel: one hour before or after meals
Preg D

Question 22

Posaconazole (Noxafil)

Answer 22

PO (with meals for better absorption)
Fungal sterol inhibitor: Triazole
aspergillosis, candida, cryptococcal
Inhib: 3A4 (strong)
caution CrCl<20
monitor: AST/ALT, CBC, Cr, Ca, K, Mg

Question 23

Ketoconazole (Nizoral)

Answer 23

PO (+food/acid) or shampoo
seborrheic dermatitis and prostate ca (inhibits androgen synthesis)
Substrate: 3A4 (major)
SE: gynecomastia, impotence, low sex drive
Preg C

Question 24

Seborrheic dermatitis DOC

Answer 24

Ketoconazole

Question 25

Invasive aspergillosis DOC

Answer 25

Voriconazole

Question 26

Clotrimazole (Lotrimin)

Answer 26

top
Fungal Sterol Inhibitor: Topical
cutaneous candida, vag candida
Insert at bedtime

Question 27

Miconazole (Monistat)

Answer 27

Top
Fungal Sterol Inhibitor: Topical
ringworm, athlete’s foot, jock itch, vag candida
insert at bedtime (vag)

Question 28

Griseofulvin (Gris Ped, Grifulvin V)

Answer 28

PO
limited to nails
Preg D/X (targets growing cells)

Question 29

Coverage for aspergillosis

Answer 29

Voriconazole, Itraconazole, Caspofungin, Ampho B, Posaconazole

Question 30

Coverage for candida

Answer 30

all exept Itraconazole and Griseofulvin

Question 31

Coverage for cryptococcal

Answer 31

Amphot B and Fluconazole

Question 32

Coverage for Histoplasmosis

Answer 32

Ketaconazole, Itraconazole, Ampho B

Question 33

Coverage for onychomycosis

Answer 33

Clotrimazole,Griseofulvin, Itraconazole, Terbinafine

Question 34

Ketoconazole - ADE

Answer 34

Gynecomastia

Question 35

Which anti fungals need an acidic environment?

Answer 35

Itraconazole and Ketoconazole

Question 36

Toenail fungus length of tx

Answer 36

12 wks

Question 37

Fingernail fungus length of tx

Answer 37

6 wks