ID-III: Antifungals Flashcards by Hannah Lapos

Yeast

Candidida
Cryptococcus

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Molds

Aspergillus
Zygomycetes

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MOA Amphotericin B

Binds to ergosterol altering cell membrane permeability and causing cell death

Broad spectrum

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Dimorphic fungi

Histoplasma
Blastomyces
Coccidiodes

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What is the difference between Amp B deoxycholate and liposomal

Liposomal has less toxicity (decreased infusion reactions and nephrotoxicity)

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BBW of Amphotericin B

Deoxycholate → cardiopulmonary arrest and death therefore should not exceed 1.5 mg/kg/d

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ADR of Ampho B

Infusion-related: fever, chills, HA, malaise, rigors
↓ K, Mg and nephrotoxic

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Describe premedication of Ampho B

Deoxycholate: requires premedication to reduce infusion-related reactions

Give 30-60 min prior to infusion:
- APAP or NSAID
- Diphenhydramine +/- hydrocortisone
- NS boluses to reduce nephrotoxicity
- +/- meperidine to reduce rigors

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How should liposomal Ampho B be prepared?

D5W and must be filtered

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Ampho B coverage

Yeast: Candida, Cryptococcus
Molds: Aspergillus and Zygomycetes
Dimorphic fungi: Histoplasma, Blastomyces, Coccidiodes

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MOA of flucytosine

Converted to FU that competes with uracil and interferes with fungal RNA and protein synthesis

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Flucytosine coverage

Combo with Ampho B due to increased resistance with mono therapy

Invasive cryptococcal or Candida

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BBW of flucytosine

Renal dysfunction caution

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ADR of flucytosine

Myelosuppression

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Azole MOA

↓ ergosterol synthesis and cell membrane formation

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Activity of fluconazole

C. albicans
C. parapsilosis
C. tropicalis

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Fluconazole resistant strains

C. glabrata
C. krusei

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Activity of itraconazole

Blastomyces and Histoplasma (nail bed infection)

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Asperigillus treatment of choice

Voriconazole

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BBW of itraconazole

HF, QTc prolongation, ventricular tacharrythmias due to DDI

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Ketoconazole BBW

Hepatotoxity, QTc prolongation

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ADR of azoles

LFTs, QTc prolongation

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What treats fungal meningitis>

Fluconazole and voriconazole due to CNS penetration

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Dose of vaginal candidiasis (fluconazole)

150 mg PO once

Voriconazole ADR

Hepatoxicity, visual disturbances, phototoxicty, QTc prolongation LFTs, sCr, CNS tox (hallucinations)

Caution of IV vori

CrCl <50; SBECD accumulations leading to renal toxicity → PO is preferred

Counseling on PO Voriconazole

Take on empty stomach 1 hr before or after meals Caution driving at night Avoid direct sunlight

Posoconazole ADR

QTc prolongation

Counseling on Posoconazole

PO: QD with food eGFR <50: SBECD can accumulate

How does Isavuconazonium differ from other azoles

QTc shortening Requires a filter prior to admin

Azoles that inhibit CYP2C9

Fluconazole and Voriconazole

All azoles are strong ___ inhibitors

CYP3A4

What azoles require an acidic gut? Non-diet cola

Itraconazole (Sporanox) and ketoconazole

MOA of echinocandins

Inhibit the synthesis of beta (1,3)-D-glucan (component of fungal cell wall)

Coverage of echinocandins

Most candida including glabrata and krusei Asperigillus as combo

ADR of echinocandins

Histamine-mediated sxWh

Which echinocandin is not QD dosing

Rezafungin

Admin of micafungin

Light protection upon admin

Fluconazole

Diflucan

Itraconazole

Sporanax

Voriconazole

Vfend

Posaconazole

Noxafil

Isavuconazonium

Cresemba

Caspofungin

Cancidas

Micafungin

Mycamine

Rezafungin

Rezzayo

Counseling of Nystatin PO

Switch and retain in mouth as long as possible before swallowing

Indication for griseofulvin

Fungal infection in skin, hair, nails

CI and ADR of griseofulvin Counseling

Pregnancy Photosensitivity, LFTs Counseling: take with fatty meals to ↑ absorption or with food/milk to avoid GI upset

Terbinafine ADR

Hepatotoxicity, HA, and ↑ LFTs

Terbinafine

Lamisil

Clotrimazole formulation

Troche/lozenge dissolve for 15-30 min

CI of miconazole

Milk protein concnetrate

Preferred for C. albicans for thrush

Mild: topical anti fungal (clotrimazole, miconazole) Mod-severe or HIV: fluconazole Alt: Nystatin

C. albicans for esophageal infection

1st: Fluconazole Alt: Echinocandins

Candida krusei and glabrata and bloodstream infection

1st: Echinocandins Alt: Ampho B, high dose fluconazole (is susceptible)

Aserigillus tx

1st: Voriconazole Alt: Ampho B, Cresemba

Cryptococcus tx

1st: Ampho B + 5-FC Alt: High-dose fluconazole + 5-FC

Dermatohphytes tx

1st: Terbinafine or Itraconazole Alt: Fluconazole