Fungal Infections Flashcards
VVC
vulvovaginal candidiasis
Uncomplicated VVC
Sporadic or infrequent
Mild to moderate infections
Likely to be C. albicans
Normal, non-pregnant women
Complicated VVC
Recurrent (> 4 episodes e/in 1 year; usually caused by azole-susceotible C. albicans)
Severe infections
Abnormal host
Uncomplicated VVC treatment
Fluconazole 150mg PO x 1
OR
Topical antravaginal azole x 1-3 days
Complicated VVC treatment
Fluconazole 150mg q72h x 3 doses
OR
Topical antivaginal azole daily x 7 days
Treatment of VVC in pregnancy
Topical antivaginal azole for 7 days (avoid systemic azoles; fluconazole is pregnancy category C)
Recurrent VVC treatment
Induction: topical or fluconazole 150mg daily for 10-14 days followed by
Suppression: fluconazole 150mg once weekly for at least 6 months
Oropheryngeal and esophageal candidiasis risk factors
Drugs - immunosuppressive, anticholinergic
Diseases - HIV, diabetes, leukemias, other malignancies, trauma, burns, xerostomia
Age - neonates or advanced age
Nutritional - vitamin B and C, iron, and folate
Other - dentures, radiation, ETT, smoking
Symptoms of oropharyngeal candidiasis
Asymptomatic
Mouth pain
Burning tongue
Metallic Taste
Symptoms of esophageal candidiasis
Dysphagia
Odynophagia
Retrosternal chest pain
Signs of oropharyngeal candidiasis
Erythema
White patches of buccal mucosa, tongue, throat or gums
No constitutional signs
Signs of Esophageal Candidiasis
Constitutional signs occasionally occur
Few to numerous white or beige plaques
Plaques may be edematous, with ulceration in severe cases
Preferred treatment of mild oropharyngeal candidiasis
Clotrimazole troche 10mg 5 times/day
OR
Miconazole mucoadhesive buccal 50mg tablet to upper gum QD x 7-14 days
Preferred treatment of moderate-severe oropharyngeal candidiasis
Fluconazole 100-200mg QD x 7-14 days
Preferred treatment of esophageal candidiasis
Fluconazole 200-400mg PO QD
OR
Fluconazole 400mg IV QD or an echinocandin
Duration: 14-21 days
Patient counseling tips
- Clean oral cavity prior to using topical agents
- Use topical agents after meals
- Troches should slowly dissolve in mouth, not chewed or swallowed whole; swallow saliva
- Suspension should be swished around mouth to cover all areas, then gargled, then swallowed
- Remove dentures before use of oral agents
- Remove and disinfect dentures overnight
- If patient has xerostomia, use suspension
- Complete course
- Maintain good oral hygiene, brush teeth twice daily, floss
- Stop smoking, avoid alcohol
Empiric therapy for non-neutropenic adults with moderately severe to severe candida
Echinocadin x 14 days after 1st negative blood cx
Empiric therapy for non-neutropenic adults with less critical candida and no recent azole exposure
Echinocandin
OR
Fluconazole 800mg x 1, then 400mg QD
For 14 days afetr 1st negative blood cx
Empiric therapy for neutropenic adults with candida
Echinocandin only
Duration: 14 days after 1st negative blood cx
When is prophylaxis recommended for Candida?
Solid-organ transplant recipients
ICU patients in an ICU with high incidence of invasive candidiasis
Chemo-induced neutropenia
Stem cell transplant recipients with neutropenia
Pregnant patients with Candida
Systemic ampho. B Avoid azoles (category C)
Candiduria clinical presentation
Generally asymptomatic
If symptomatic, would be similar to bacterial cystitis and pyelonephritis
Candiduria diagnosis
Suggestive
10,000 organisms or visualization of both yeast and pseudohyphae from fresh midstream urine or from single catheterization urine collections
Treatment of asymptomatic cystitis with possible candida
Treatment usually not indicated unless at risk
If undergoing urologic procedure: fluconazole or ampho. B for several days before and after procedure
Treatment of symptomatic cystitis with possible candida
Fluconazole 200mg QD x 2 weeks
Treatment of Pyelonephritis with possible candida
Fluconazole 200-400mg QD x 2 weeks
Aspergillosis
Spectrum of disease attributed to allergy, colonization or tissue invasion caused by members of the fungal genus Aspergillus
3 most common species of Aspergillus
A. fumigatus
A. flavus
A. niger
Most common Aspergillus species in infections
A. fumigatus
Pathophysiology of aspergillus infections
Produce conidia
Considered opportunistic pathogen
Conidia
Aerial hyphal stalks
Inhaled
Growth results in pulmonary inflammation, tissue destruction, and potential dissemination into other organs
Allergic bronchopulmonary aspergillosis
BPA
A. fumigatus
Clinical presentation: severe asthma with wheezing, fever, malaise, weight loss, chest pain, and productive cough with blood tinged sputum
Aspergilloma
Sinuses, pulmonary
Treatment:
-Single: no therapy or surgical removal
-Chronic cavitary pulmonary: similar to invasive pulmonary aspergillosis
Invasive aspergillosis (IA) risk factors
Drugs - high dose corticosteroids, immunosuppressants, cytotoxic agents, receiving multiple ABX
Diseases - leukopenia, alcoholism, leukemia/lymphoma, DM, immunodeficiency diseases, chronic granulomatoud disease, chronic hepatitis
IA clinical presentation
Lung is common site (also liver, CNS, spleen)
Vascular invasion leads to thrombosis, infarction, necrosis, dissemination
Variable presentation, but pulmonary IA usually involves fever, hemoptysis, cough and chest pain
Often rpesents late after infection, sometimes after dissemination has occured
IA diagnosis
Galactomannan antigen
Cultures of the respiratory tract
Tissue biopsy - definitive
Radiographic studies: Chest xray, CT scans
IA therapy
Voriconazole 6mg/kg IV q12h x 1, then 4mg/kg IV q12h
Oral maintenance: 200-300mg q12h or weight based
IA duration of therapy
Not well defined
Minimum 6-12 weeks
IA prophylaxis
Not typically recommended.
Recommended for patients with prolonged neutropenia who are at high risk for invasive aspergillosis. Also appropriate for immunocompromised who were successfully treated for IA.
DOC: Posaconazole
