Invasive Fungal Infections Flashcards
What are the signs and symptoms of candidiasis?
fever, tachycardia, tachypnea, chills, hypotension
similar to bacteremia, hard to differentiate
What are the risk factors for candidiasis?
broad-spectrum antibacterial agents
central venous (CVC, PICC) and urinary catheters
receipt of parenteral nutrition
neutropenia (ANC </=500cells/mm^3)
receipt of immunosuppressive agents
surgery (intra-abdominal)
intrabdominal perforation
ICU length of stay
hemodialysis/renal replacement therapy
implantable prosthetic devices
What is the treatment for candidemia?
echinocandin (if don’t know species yet):
micafungin 100mg IV daily
caspofungin 70mg IV loading dose, 50mg daily
anidulafungin 200mg IV loading dose, 100mg daily
fluconazole: 800mg loading dose, then 400mg PO/IV daily
get susceptibility testing done in all blood stream and clinically relevant isolates!
treat for 14 days after 1st negative blood culture
What do we use to help choose empiric therapy?
antibiogram
want above 90%, 80% is the hard cutoff
What are alternative therapies for candidemia treatment?
amphotericin B formulation 3-5mg/kg/day
voriconazole 400mg BID x 2 doses then 200mg BID
What are candidemia treatment considerations?
narrow to oral therapy: need susceptibilities, needs to be clinically stable, negative repeat blood cultures, been on therapy for 48hrs, choose most narrow agent
remove the line!!!!
repeat blood cultures q48hrs
What is candidemia treatment for neutropenic patient?
may need broader therapy due to exposure
echinocandin - initial therapy: caspofungin 70mg loading dose, 50mg daily
micafungin 100mg daily
anidulafungin 200mg loading dose, 100mg daily
lipid fomulation of amphotericin B 3-5mg/kg/day
If neutropenic patient with candidemia is not critically ill and no prior azole exposure, what is the treatment?
fluconazole 800mg loading dose, 400mg daily
voriconazole 400mg BID x2 doses, then 200-300mg BID if additional mold coverage needed
What is the clinical presentation of disseminated histoplasmosis?
- May be seen in patients exposed to large inoculum or in immunocompromised host (especially if decreased cell mediated immunity)
- Symptoms: fever, chills, fatigue, weight loss, night sweats, hepatosplenomegaly, cough, chest pain, dyspnea
- CNS histoplasmosis symptoms: fever, headache, seizure, mental status changes
What is the treatment of histoplasmosis in immunocompetent host (acute pulmonary histoplasmosis)? - Asymptomatic or mild-moderate disease with symptoms < 4 weeks
NO therapy required
What is the treatment of histoplasmosis in immunocompetent host (acute pulmonary histoplasmosis)? - Mild-moderate disease with symptoms > 4 weeks
Itraconazole 200mg TID x3days, then 200mg QD or BID for 6-12 weeks
What is the treatment of histoplasmosis in immunocompetent host (acute pulmonary histoplasmosis)? - Moderately severe-severe disease
Lipid amphotericin B 3-5mg/kg/day x1-2 weeks, then itraconazole 200 mg TID x 3 days followed by 200 mg BID for total of 12 weeks
Methyl prednisolone 0.5-1mg/kg daily for first 1-2 weeks
What is the treatment of histoplasmosis for immunocompromised host (disseminated histoplasmosis)? - Moderately severe-severe disseminated disease
Lipid amphotericin B 3-5 mg/kg/day x 1-2 weeks, then itraconazole 200 mg TID x 3 days followed by 200 mg BID for at least 12 months
What is the treatment of histoplasmosis for immunocompromised host (disseminated histoplasmosis)? - less severe disease
Itraconazole 200 mg TID x 3 days followed by 200 mg BID x 12 months
What are treatment considerations for coccidioidomycosis?
primary respiratory infection: most pts with symptomatic primary pulmonary disease recover without therapy
Treat patients with large inocula, severe infection, or concurrent risk factors (e.g., HIV infection, organ transplant, pregnancy, or high doses of corticosteroids)
What are signs of a severe infection in coccidioidomycosis?
- Weight loss (> 10%), intense night sweats persisting > 3 weeks
- Infiltrates involving more than one half of one lung or portions of both lungs, prominent or persistent hilar adenopathy
- Complement fixation antibody titers > 1:16
- Inability to work (extreme fatigue), or symptoms that persist > 2 months
What is the treatment for coccidioidomycocis - primary respiratory infection?
- Fluconazole 400-800 mg PO/IV daily
- Itraconazole 200-300 mg PO BID-TID
- Treat 3-6 months
What is the treatment for coccidioidomycocis - symptomatic chronic cavitary pneumonia?
- Fluconazole 400-800 mg PO/IV daily
- Itraconazole 200-300 mg PO BID-TID
- Treat for 12 months total
What is the treatment for coccidioidomycocis - diffuse pneumonia with bilateral or miliary infiltrates?
- Amphotericin B (lipid or deoxycholate) for several weeks, followed by an azole
- Treat for 12 months total
What is the causative pathogen of cryptococcosis?
Cryptococcus neoformans and Cryptococcus gattii
* C. neoformans in immunocompromised host
* C. gattii in immunocompetent host
Cell-mediated immunity plays a major role in host defense against infection
What is the clinical presentation of cryptococcosis?
- Pulmonary: Cough, rales, shortness of breath
- Meningitis: Patients without HIV - Headache, fever, nausea, vomiting, mental status changes, nuchal rigidity; Less common – photophobia, blurred vision, papilledema, seizures, hydrocephalus
- Patients living with HIV: Fever, malaise, headache; Tend to have less symptoms due to reduced immune system
What is the diagnosis of cryptococcosis?
meningitis (most common presentation):
* Perform a lumbar puncture and look at fluid: Increased CSF opening pressure; Increased CSF WBCs (lymphocytes); Decreased CSF glucose; Increased CSF protein
* Positive CSF (and serum) cryptococcal antigen
* Rapid diagnostics as well to detect DNA in blood and CSF
* Culture (both LP and blood)
* Reduced inflammatory response in HIV/AIDS with extremely high cryptococcal antigen titer
What is the treatment for cryptococcal meningitis in non-HIV infected, non-transplant host? - induction
- amphotericin B deoxycholate 0.7-1mg/kg/day or lipid amphotericin B 3-5 mg/kg/day IV plus flucytosine 100 mg/kg/day PO in 4 divided doses for at least 4 weeks
- 4 weeks in patients without neurologic complications and negative
- CSF cultures after 2 weeks of therapy
- 4 to 6-week induction phase for C.gattii
- Extend induction phase to 6 weeks if neurologic complications or flucytosine not given
What is the treatment for cryptococcal meningitis in non-HIV infected, non-transplant host? - consolidation
fluconazole 400-800mg PO daily x8 weeks
