Fungal infections

Question 1

Which azole is not recommended in CrCL less than 50 mL/min?

Answer 1

Voriconazole

Question 2

Which azole has solution and capsule formulations that are not interchangeable?

Answer 2

Itraconazole

Question 3

Which azoles have therapeutic drug monitoring?

Answer 3

Voriconazole, posaconazole

Question 4

Which azole can replace voriconazole in pts with renal issues?

Answer 4

Isavuconazole

Question 5

Echinocandin - formulation

Answer 5

Only available IV

Question 6

Echinocandin - loading dose for which?

Answer 6

Capsofungin and anidulafungin

NOT micafungin

Question 7

Pretreatments for amphotericin?

Answer 7

Infusion related side effects - chills, rigor, fever
Pre-treat with APAP and diphenhydramine

Renal toxicity - give normal saline before and after

There can be electrolyte wasting so may have to treat that

Question 8

Which drug must be used in combination?

Answer 8

Flucytosine

Question 9

Which drug can cause bone marrow suppression?

Answer 9

Flucytosine

Question 10

How to treat Candidemia?

Answer 10

Echinocandin first line

Fluconazole IV/PO 800 mg loading then 400 mg daily OK if not critically ill/no resistance (no recent azole use)

Duration: Clearance of blood culture plus 2 weeks

Question 11

When do you check for azole susceptibility?

Answer 11

All patients

Question 12

When do you check for echinocandin susceptibility?

Answer 12

In patients with prior use or infected with C glabrata or C parapsilosis

Question 13

What is candiduria? When do we treat?

Answer 13

Candida part of the urogenital normal flora

Onlu treat if symptomatic, neutropenic, very low birth weight neonate, or urologic manipulation occurred

Question 14

How to treat candiduria?

Answer 14

Fluconazole oral

Question 15

What is vulvovaginal candidiasis?

Answer 15

Yeast infection

Uncomplicated: Sporadic, responds to any/all antifungals

Complicated: Recurrent, severe, non-C albicans species, host factors (immunosuppression)

Question 16

How to treat vulvovaginal candidiasis?

Answer 16

Uncomplicated: Topical azoles, or fluconazole 150 mg 1 dose

Severe, acute: Fluconazole 150 mg q72 hours x 2-3 doses

Recurrent: 10-14 days induction with topical or oral azole, then fluconazole 150 mg every week for 6 months

Nonresponsive C glabrata infection: Boric acid, nystatin, or flucytosine with or without amphotericin B cream

Question 17

How to treat OPC?

Answer 17

Oropharyngeal candidiasis:

Mild disease use clotrimazole troches, miconazole mucoadhesive buccal tablets

Moderate/severe: Fluconazole

Duration: 7-14 days

Question 18

How to treat EC?

Answer 18

Esophageal candidiasis

MUST use systemic treatment

Preferred: Fluconazole 200-400 mg PO daily x 14-21 days (3-6 mg/kg)

Can use Fluconazole 400 mg IV or Echinocandin if PO cannot be tolerated (bc you know it’s esophageal)

Question 19

How to treat Pulmonary aspergillosis?

Answer 19

EARLY

Use voriconazole IV or PO 6 mg/kg q12h for 1 day then 4 mg/kg every 12 hours

Duration: 6-12 weeks at least

Immunosuppressed pts: Continue during immunosuppression and while lesions are present

Immunosuppressant patients successfully treated requiring continued immunosuppression should continue treatment bc they’re still at risk for another infection