Exam 5 - Antifungals Tieman Flashcards by Rehman Hameed

for candida infections, we see increased mortality if empiric antifungal therapy is delayed by ___ hours

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risk factors for invasive candidiasis (7)

-prolonged ICU stay
-central venous catheters
-prolonged therapy with broad spec. antibiotics
-receipt of parenteral nutrition
-recent surgery (especially abdominal)
-hemodialysis
-diabetes mellitus

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which of the following is TRUE about aspergillus?

a. it is a virus that is ubiquitous in the environment
b. primarily causes disease in immunocompromised hosts (neutropenia)
c. cardiovascular system is most common infection
d. definitive diagnosis requires a negative culture from a sterile site

b. primarily causes disease in immunocompromised hosts (neutropenia)

(a. is mold; c. is pulmonary system; d. is positive)

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T or F: for aspergillus infections, we can use histologic or radiologic evidence in a high risk pt with negative cultures

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3 endemic fungi (slide 9)

histoplasma capsulatum
blastomyces spp.
coccidioides spp.

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which of the following endemic fungi is NOT typically found in Indiana?

a. histoplasma capsulatum
b. blastomyces spp.
c. coccidioides spp.

c. coccidioides spp.

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two common cryptococcus species (slide 10)

-cryptococcus neoformans
-cryptococcus gatti

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cryptococcus is an encapsulated yeast that primarily affects the _____ and respiratory tract

CNS

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amphotericin B is first line for which of the following fungi? SELECT ALL THAT APPLY (4)

a. candida
b. cryptococcus
c. blastomyces
d. histoplasma
e. coccidioides
f. aspergillus
g. mucor

b, c, d, g

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amphotericin B is commonly used as initial agent in _______ _______ fungal infections such as Histoplasmosis / Blastomyces and Cryptococcal meningitis

systemic invasive

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amphotericin B deoxycholate dose

a. usual 0.5-1 mg/kg/day
b. 3-5 mg/kg daily
c. 5 mg/kg daily

a. usual 0.5-1 mg/kg/day

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amphotericin B liposomal dose

a. usual 0.5-1 mg/kg/day
b. 3-5 mg/kg daily
c. 5 mg/kg daily

b. 3-5 mg/kg daily

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amphotericin B lipid complex

a. usual 0.5-1 mg/kg/day
b. 3-5 mg/kg daily
c. 5 mg/kg daily

c. 5 mg/kg daily

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T or F: dosing for amphotericin B is based on actual body weight

F (ideal or adjusted)

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amphotericin B has a AE of dose-dependent _______

a. hepatotoxicity
b. myelosuppression
c. adrenal toxicity
d. nephrotoxicity

d. nephrotoxicity (inc in SCr and BUN)

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prevention of nephrotoxicity due to amphotericin B

0.5-1 L NS over 30 min before infusion and 0.5-1 L NS after infusion

(pre and post treat with fluids)

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3 electrolyte abnormalities associated with amphotericin B (slide 17)

-hypokalemia
-hypomagnesemia
-bicarb wasting

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which of the following is NOT an electrolyte abnormality seen with amphotericin B tx?

a. hypophosphatemia
b. hypokalemia
c. hypomagnesemia
d. bicarb wasting

a. hypophosphatemia

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which of the following is FALSE about flucytosine?

a. > 90% bioavailability
b. does not penetrate into CSF
c. 85-95% excreted unchanged in urine
d. half life is 3-5 hours
e. goal peak 70-80; goal trough 20-40

b. does not penetrate into CSF

(main use is combo with AmphoB for cryptococcal meningitis)

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flucytosine is first line for which of the following fungi? (1)

a. candida
b. cryptococcus
c. blastomyces
d. histoplasma
e. coccidioides
f. aspergillus
g. mucor

b. cryptococcus

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which AE of flucytosine is associated with high peak concentrations?

a. hepatotoxicity
b. myelosuppression
c. GI upset
d. anorexia

b. myelosuppression (bone marrow suppression)

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monitoring for flucytosine (4 things)

CBC, SCr, BUN, platelets

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which of the following is FALSE about fluconazole?

a. > 90% bioavailability
b. decent CSF concentration
c. excreted unchanged in urine
d. dosing based on adjusted BW
e. half life ~ 30 hours

d. dosing based on adjusted BW (based on TOTAL body weight)

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T or F: fluconazole needs dose reduction in renal insufficiency

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first line clinical use of fluconazole a. noninvasive candidiasis b. invasive candidiasis (aka candidemia) c. prophylaxis in bone marrow transplant d. cryptococcal meningitis

b. invasive candidiasis (aka candidemia)

fluconazole dose for invasive candidiasis if "c. albicans" a. 800 mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) daily b. 800 mg daily (loading dose 1200-1600 mg) c. 800 mg daily for 10-12 weeks after CSF negative d. 400 mg daily

a. 800 mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) daily

fluconazole dose for invasive candidiasis if "c. glabrata" a. 800 mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) daily b. 800 mg daily (loading dose 1200-1600 mg) c. 800 mg daily for 10-12 weeks after CSF negative d. 400 mg daily

b. 800 mg daily (loading dose 1200-1600 mg)

fluconazole dose for cryptococcal meningitis: CONSOLIDATION therapy a. 400 mg daily for at least 1 year AND asymptomatic AND CD4 count 100 for 3 months b. 800 mg daily for 10-12 weeks after CSF negative c. 800 mg loading dose, then 400 mg daily d. 800 mg daily after loading dose of 1200-1600 mg

b. 800 mg daily for 10-12 weeks after CSF negative

fluconazole dose for cryptococcal meningitis: MAINTENANCE therapy a. 400 mg daily for at least 1 year AND asymptomatic AND CD4 count 100 for 3 months b. 800 mg daily for 10-12 weeks after CSF negative c. 800 mg loading dose, then 400 mg daily d. 800 mg daily after loading dose of 1200-1600 mg

a. 400 mg daily for at least 1 year AND asymptomatic AND CD4 count 100 for 3 months

which of the following is NOT an AE of fluconazole? a. QTc prolongation b. peripheral neuropathy c. anorexia d. adrenal insufficiency

b. peripheral neuropathy

fluconazole is first line for which of the following fungi? SELECT ALL THAT APPLY (5) a. candida albicans b. candida glabrata c. candida parapsilosis d. candida tropicalis e. candida krusei f. candida lusitaniae g. candida auris h. cryptococcus i. blastomyces j. histoplasma k. coccidioidies l. aspergillus m. mucor

a, c, d, f, k

itraconazole is metabolized mainly by which CYP? a. CYP2D6 b. CYP2C9 c. CYP2E1 d. CYP3A4

d. CYP3A4

which of the following is TRUE about itraconazole? a. active metabolite is methylitraconazole b. clearance increases with higher doses due to saturable hepatic metabolism c. absorption after taking oral capsule is NOT dependent on gastric acidity d. absorption after taking oral solution is NOT affected by gastric acidity

d. absorption after taking oral solution is NOT affected by gastric acidity (a. is hydroxyitraconazole; b. is decreases; c. is dependent)

which is better absorbed, itraconazole capsules or oral solution?

oral solution

itraconazole is first line for which of the following clinical uses? SELECT ALL THAT APPLY (2) a. histoplasmosis b. aspergillosis c. blastomycosis d. life-threatening infections e. onychomycosis of toenails f. onychomycosis of fingernails

a, c

itraconazole dosage for histoplasmosis and blastomycosis a. 200 mg PO TID x 3 days, then 200 mg PO BID b. 200 mg PO BID c. 200 mg PO daily for 12 weeks d. 200 mg PO BID for 1 week; repeat 3 weeks later

a. 200 mg PO TID x 3 days, then 200 mg PO BID (b. is aspergillosis; c. is for onychomycosis of toenails; d. is for onychomycosis of fingernails)

itraconazole black box warning a. GI ulcers b. pancreatitis c. CHF d. suicidal ideation

c. CHF (due to negative inotropic effect)

serum trough itraconazole concentration (range)

> 0.5-1

itraconazole troughs > ___ combined itraconazole and hydroxyitraconazole associated with efficacy

> 1.5 (> 3 associated with inc AEs)

which of the following is TRUE about posaconazole? a. oral suspension's absorption is not affected by gastric pH b. IR tablets are the preferred oral formulation c. suspensions and tablets are better absorbed without food d. avoid if CrCl < 50

d. avoid if CrCl < 50 (a. is affected; b. is delayed release; c. is better with food)

IV formulations of posaconazole contain _______

cyclodextrin

which of the following is NOT an AE of posaconazole? a. QTc prolongation b. decreased AST/ALT/bilirubin c. hypokalemia d. pseudohyperaldosteronism

b. decreased AST/ALT/bilirubin (increased)

which of the following is FALSE about voriconazole? a. dose adjustment needed in oral dosing b. metabolized by CYP2C19, 2C9, and 3A4 c. avoid IV if CrCl < 50 d. oral bioavailability is not affected by H2RAs, PPI, antacids

a. dose adjustment needed in oral dosing (not needed in oral; avoid IV if CrCl < 50 due to vehicle)

voriconazole is first line for which of the following fungi? (1) a. cryptococcus b. blastomyces c. histoplasma d. coccidioides e. aspergillus f. mucor

e. aspergillus

T or F: voriconazole is used for invasive aspergillosis

voriconazole loading dose for invasive aspergillosis a. 2 mg/kg IV q12h for first 24 hours b. 4 mg/kg IV q12h for first 24 hours c. 6 mg/kg IV q12h for first 24 hours d. 10 mg/kg IV q12h for first 48 hours

c. 6 mg/kg IV q12h for first 24 hours

voriconazole maintenance dose for invasive aspergillosis (IV and oral)

IV: 4 mg/kg q12h oral: 200 mg q12h

which of the following is NOT an AE of voriconazole? a. visual disturbances b. elevated liver function tests c. phlebitis d. QTc prolongation e. photoxic skin reactions f. diffuse, painful periostitis

c. phlebitis

voriconazole adverse effects: diffuse, painful periostitis is secondary to excess _______ a. bromide b. fluoride c. chloride d. neon

b. fluoride (voriconazole contains fluorine)

which of the following is NOT an AE of isavuconazole? a. QTc prolongation b. N/V/D c. hypokalemia d. hepatotoxicity e. hypersensitivity rxns

a. QTc prolongation (can actually shorten)

which azole is considered to have the least drug interactions in the azole family? a. fluconazole b. voriconazole c. isavuconazole d. ketoconazole

c. isavuconazole

which of the following is NOT a CI for isavuconazole? a. co-admin with strong 3A4 inhibitors b. co-admin with strong 3A4 inducers c. familial short QT syndrome d. nephrotoxicity

d. nephrotoxicity

echinocandins are first line for which of the following fungi? SELECT ALL THAT APPLY (4) a. candida albicans b. candida glabrata c. candida parapsilosis d. candida tropicalis e. candida krusei f. candida lusitaniae g. candida auris

b, e, f, g

we may add _______ to voriconazole in severe aspergillus infections a. micafungin b. caspofungin c. anidulafungin d. rezafungin

a. micafungin

which of the following is NOT an AE of caspofungin? a. phlebitis at infusion site b. QTc prolongation c. fever d. histamine-related sx

b. QTc prolongation

which of the following is NOT a lab value change seen with caspofungin? a. inc liver transaminases b. dec potassium c. dec in urine protein and RBCs d. dec hemoglobin/hematocrit

c. dec in urine protein and RBCs (increase)

which of the following is FALSE about micafungin? a. PO only b. no dose adjustment for renal dysfunction c. not metabolized by CYP450 pathways d. half life 14-17 hours

a. PO only (IV)

hyperbilirubinemia and eosinophilia are AE of a. caspofungin b. micafungin c. anidulafungin

b. micafungin

clinical use of ibrexafungerp

vulvovaginal candidiasis (VVC)

ibrexafungerp dose for vulvovaginal candidiasis

300 mg (2-150 mg tablets) twice a day for one day (total dose 600 mg)

T or F: ibrexafungerp can be used in pregnancy

F (CI; use contraception during and for 4 days after tx)

for ibrexafungerp, how long should effective contraception be used?

during and for 4 days after tx

fluconazole is first line DOC for all of the following candida species EXCEPT: a. albicans b. parapsilosis c. tropicalis d. krusei e. lusitaniae

d. krusei

echinocandins are first line DOC for all of the following candida species EXCEPT: (slide 61) a. albicans b. glabrata c. krusei d. lusitaniae e. auris

a. albicans

fluconazole is first line DOC for which of the following? SELECT ALL THAT APPLY (2; slide 80) a. cryptococcus b. blastomyces c. histoplasma d. coccidioides e. aspergillus f. mucor

a, d

itraconazole is first line DOC for which of the following? SELECT ALL THAT APPLY (2) a. cryptococcus b. blastomyces c. histoplasma d. coccidioides e. aspergillus f. mucor

b, c

voriconazole is first line DOC for which of the following? (1) a. cryptococcus b. blastomyces c. histoplasma d. coccidioides e. aspergillus f. mucor

e. aspergillus

amphotericin B is first line DOC for which of the following? SELECT ALL THAT APPLY (2) a. cryptococcus b. blastomyces c. histoplasma d. coccidioides e. aspergillus f. mucor

a, f

flucytosine is first line DOC for which of the following? (1) a. cryptococcus b. blastomyces c. histoplasma d. coccidioides e. aspergillus f. mucor

a. cryptococcus

primary line of host defenses against superficial candida infections is _____-_______ _______

cell-mediated immunity (mediated by CD4 T-cells)

which of the following is a systemic risk factor for oropharyngeal and esophageal candidiasis? a. receiving an organ transplant b. use of inhaled steroids c. smoking d. disruption of oral mucosa due to chemotherapy and radiotherapy

a. receiving an organ transplant

what disease state is being described? -dysphagia, odynophagia, and chest pain are common -fever, few to numerous white plaques of varying size -upper GI endoscopy with biopsy used

esophageal candidiasis

how long is tx for oropharyngeal candidiasis? a. 3-5 days b. 5-7 days c. 7-14 days d. 14-21 days

c. 7-14 days

topical therapy options for mild infection oropharyngeal candidiasis (3; no doses)

-clotrimazole troche -nystatin suspension -miconazole buccal tablet

which of the following is FALSE about mild oropharyngeal candidiasis tx? a. hold clotrimazole troches in mouth for 15-20 minutes; 5x/day b. swish and swallow 15 mL of nystatin 100,000 units/mL four times a day c. miconazole 50 mg mucoadhesive buccal tablet should be applied to upper gums daily x 7-14 days d. if miconazole tablet falls off and swallowed in first 6 hours, apply new tablet e. you can eat and drink with miconazole buccal tablet, but don't chew gum

b. swish and swallow 15 mL of nystatin 100,000 units/mL four times a day (it should be 5 mL QID)

how long is tx for esophageal candidiasis? a. 3-5 days b. 5-7 days c. 7-14 days d. 14-21 days

d. 14-21 days

T or F: systemic therapy for esophageal candidiasis is always required

fluconazole dose for esophageal candidiasis

200-400 mg PO/IV daily

uncomplicated vulvovaginal candidiasis a. sporadic infection that is susceptible to all forms of antifungal therapy regardless of treatment duration b. recurrent VVC; severe disease; non-Candida albicans infection; host factors (DM, immunosuppression, pregnancy)

a. sporadic infection that is susceptible to all forms of antifungal therapy regardless of treatment duration

complicated vulvovaginal candidiasis a. sporadic infection that is susceptible to all forms of antifungal therapy regardless of treatment duration b. recurrent VVC; severe disease; non-Candida albicans infection; host factors (DM, immunosuppression, pregnancy)

b. recurrent VVC; severe disease; non-Candida albicans infection; host factors (DM, immunosuppression, pregnancy)

which of the following is TRUE about vulvovaginal candidiasis? a. contraceptive agents dec risk b. antibiotic use does not play a role in development of VVC c. associated with diet changes d. topical preparations can dec efficacy of latex condoms and diaphragms

d. topical preparations can dec efficacy of latex condoms and diaphragms (a. is inc; b. is a factor; c. is not associated)

for uncomplicated VVC, cure rates are 80-95% with topical or oral azoles, and 70-90% with ______

nystatin