DS: Opportunistic Infection

Question 1

Infectious complications following hematopoeitic stem cell transplantation (HCT)

Answer 1

Question 2

Immunosuppressive effects of common medications

Answer 2

Question 3

Initial inpatient management of fever in NF cancer patient

Answer 3

Question 4

Indications for addition of expanded GP coverage in NF cancer patient

Answer 4

Question 5

Comparison of azole antifungal

Answer 5

Question 6

Drug interaction with azole antifungal

Answer 6

Major Consideration = DDI
Qt prolongation also an issue (Except for isavuconazonium sulfate)

Question 7

NCCN Guidelines for antifungal ppx in cancer patients

Answer 7

Question 8

IDSA Guidelines for antifungal ppx in cancer patients

Answer 8

Ppx against Candida is recommended in patient at substantial risk (e.g. allogenic HCT recipient, patient receiving intensive induction chemotherapy for acute leukemia

Ppx against Aspergillus is recommended in selected patients receiving intensive chemotherapy for acute leukemia
Antifungal ppx is not recommended in low risk patient

Question 9

Prophylaxis for Pneumocystis jirovecii in Cancer patient

Answer 9

Question 10

Antiviral ppx in cancer patients

Answer 10

Question 11

Antiviral ppx nin solid organ transplant recipients

Answer 11

Question 12

Forscarnet vs. Ganciclovir for treatment of CMV reactivation in HCT recipients

Answer 12

Foscarnet and ganciclovir are similarly effective in the treatment of early CMV reactivation in HCT recipients

Ganciclovir associated with more frequent myelosupression

Foscarnet associated with more frequent renal toxicity and electrolyte abnormalities than ganciclovir

Choice will be depending on patient risk and tolerance:
Foscarnet may be preferred if patient has myelosuppression or at high risk for myelosuppressive adverse event
Ganciclovir may be preferred if patient has renal/electrolyte abnormality

Question 13

CMV Treatment in Allogeneic HCT Recipients

Answer 13

Question 14

CMV Treatment in solid organ transplant recipients

Answer 14

Question 15

Treatment of antiviral resistant CMV

Answer 15

Question 16

Treatment of antviral resistant CMV - refractory treatment

Answer 16

Maribavir - It cannot be coadminister with (val)gannciclovir

Question 17

Invasive Fungal Infection - Host Criteria

Answer 17

Question 18

Clinical Criteria for IFI (invasive fungal infection)

Answer 18

Question 19

Invasive Aspergillosis - Diagnosis

Answer 19

Aspergillus is a ubiquitous mold found in the environment → most common invasive mold infection in immunocompromised patients

Indirect serum test:
1. Gallactoommannan → component of aspergillus cell wall released into systemic circulation in angioinvasive disease
Serrum and/or bronchoalveolar lavage galactomannan recommended as diagnostic marker for IA
Cross reactivity with Fusarium, Scedosporium, other less common molds

2. (1 → 3) beta-D-glucan - component of cell wall in many fungi
   Although not specific for Aspergillus
   High rate of false positivity due to cross reactivity with yeast (including candida)

Question 20

Treatment of invasive pulmonary aspergillosis - IDSA

Answer 20

Question 21

Is there a role for front-line combination therapy for invasive pulmonary aspergillosis

Answer 21

Per IDSA: suggest consideration for an echinocandin with voriconazole for primary therapy in the setting of severe disesae especially in patient with hematologic malignancy and those with profound and persistent neutropenia

Question 22

Target trough of azole antifungal

Answer 22

Upper limit with voriconazole is due to hallucinations/visual effects and hepatobiliary concerns

Voriconazole level above 1 mcg/ml has been shown to lead to improved outcome

No max trough associated with toxicity with respect to posaconazole

Question 23

Isavuconazonium Sulfate and posaconazole for invasive aspergillus

Answer 23

Conclusion: Cresemba and posaconazole are non inferior and roughly equivalent to voriconazole in patient with invasive Aspergillus

Both favorable adverse event profile, better tolerated than voriconazole

Still not the first line option - less clinical experience, cost consideration and lack of awareness and timing of guidelines release.

Question 24

Invasive Mucormycosis

Answer 24

Question 25

Treatment of mucormycosis

Answer 25