Exam #4: Invasive Fungal Infections (Metzger) Flashcards
Describe the fungal outbreak in 2012
- a compounding pharmacy produced “products” contaminated with fungus that was used to inject in patients w/ inflammatory joint issue.
- 64 patients died
Characteristics of Fungi? (3)
- eukaryotes w/ defined nucleus
- rigid CELL WALL (made up of chitin)
- cytoplasmic membrane
T/F Fungal susceptible are MORE reliable than bacterial susceptibilities
FALSE:
fungi grow a lot more slower than bacteria
What plays an important role in the clinical outcome of patients with fungal infections?
host factors
if a pts WBC are suppressed, then its hard to get rid of the infection even if you have the right agent
_______ therapy is key for fungal infections
empiric
based on risk factors, signs and symptoms, etc
T/F There are NO reliable breakpoints for amphtericin B
TRUE
Fluconazole
Diflucan
Itraconazole
Sporanox
Voriconazole
Vfend
Posaconazole
Noxafil
Isavuconazole
Cresemba
_____ is used most commonly for CANDIDA INFECTIONS in the hospital; ONLY given intravenously
echinocandins
- Caspofungin
- Micafungin
- Anidulafungin
What are 2 things that we worry about with Amphotericin?
- infusion related reactions
- toxicities
The ______ formulations of Amphotericin commonly cause INFUSION RELATED REACTIONS (fever, flushing, rigors, myalgia). What should be done to prevent this?
conventional (deoxycholate)
need to premeditate 30 mins prior to administration
What are the 5 options to premeditate pts with prior to receiving Amphtericin?
- HYDROCORTISONE
- IBUPROFEN
- MEPERIDINE
- acetaminophen
- diphenhydramine
What TOXICITIES are associated with Amphotericin? (3)
- hypoKALEMIA
- hypoMAGNESEMIA
- acute kidney injury
T/F The liposomal and lipid formulations were created to specifically prevent AKI caused by Ampho
TRUE
What can be done to prevent AKI toxicity associated with Amphotericin?
500 mL of normal saline bolus BEFORE and AFTER EACH DOSE
When should a pharmacist consider therapeutic drug monitoring(TDM)? (3)
- sensitive assay with QUICK LAB reporting
- well-established therapeutic RANGE
- inter-patient drug variability
What 4 antifungals SHOULD have TDM?
- flucytosine
- Itraconazole
- voriconazole
- posaconazole suspension
Tertiary care medical centers have a growing rate of …..
non-albicans candida
What candida species?
-found on skin, GI, and genital tract
candida albicans
What candida species?
-NOT AS susceptible to fluconazole
candida glabrata
What candida species?
- sensitive to fluconazole
- seen in w/ TPNs often
candida parapsilosis
What candida species?
-resistant to a LOT of drugs
candida auris
What candida species?
-INTRINSICALLY RESISTANT to fluconazole
candida krusei
Diagnosis for CANDIDIASIS is based on: (3)
- persisent signs of infection despite antibacterial agents
- risk factors
- blood cx POS for yeast
T/F Yeast grown in a culture is a contaminate
FALSE: NEVER a contaminant
Primary or Intrinsic resistance
resistant prior to anti fungal exposure
secondary OR acquired resistance
- adaptations
- mutations
______ is known as neutropenia
less than 1500 neutrophils
_____ is known as SEVERE neutropenia
less than 500 neutrophils
decreases ability for the immune system to eradicate pathogens
How do you calculate ABSOLUTE NEUTROPHIL COUNT (ANC)?
WBC * (% neutrophils + % bands)
How long is tx for candidiasis?
at least 14 days
can possible de-escalate to diflucan after 5-7 days (if susceptible)
What is the DOC for INVASIVE CANDIDIASIS (for neutropenic and non-neutropenic?
Echinocandin (Caspofungin, Micafungin, Anidulafungin)
neutropenic: also the option of Lipid Ampho B
What is necessary for pts with CANDIDIASIS?
need an eye exam to make sure the pt DOES NOT have ocular disease (endophthalmitis)
What is the RISK FACTOR for Aspergillosis?
immunosuppression
What is key for diagnosis of Aspergillosis?
radiologic evidence (present OR halo sign on the CT of the chest in the lung)
Postive glactomannan essay is indicative of?
probable aspergillosis
What is the DOC for aspergillosis?
Voriconazole
How long is the tx for Aspergillosis?
6-12 weeks
What is the Voriconazole trough concentration 4-7 days after starting treatment GOAL for Aspergillosis?
1- 5.5 mg/L
greater than 1: better efficacy
less than 5.5: better safety
RISK Factors for cryptococcosis (2)
*HIV/AIDS
(CD4 count less than 50 cells/mm)
*Immunosuppression
Presentation of cryptococcosis in
- nonimmunosuppressed: _____________
- HIV/AIDs: _______
nonimmunosuppressed: pulmonary infection
HIV/AIDs: meningitis
Diagnosis of cryptococcosis (2)
- CSF (lymphocytic)
* POS serum cryptococcal antigen
Duration of histoplasmosis vs. blossomycosis
histoplasmosis = weeks blastomycosis = months
Steady state for ITRACONAZOLE is achieved around _______.And the target is ____________
2 weeks
0.5 mcg/mL - 10.0 mcg/mL
