Kays Fungal Infection Flashcards
Oropharyngeal candidiasis is
an Infection of the oral mucosa with Candida species
Esophageal candidiasis is
an Infection of the esophagus with Candida species
Candida are normal flora in the GI tract and what is the most common candida in the GI tract
C. albicans
Most common opportunistic infection in HIV patients
OPC
What is the primary line of host defenses against superficial Candida infections is
cell mediated immunity
Risk Factors for OPC and EC
- steroid use
- dentures
- xerostomia due to drugs , chemo, and radiotherap
- smoking
- disruption of oral mucosa
- drugs
- neonates or elderly
- HIV infection/AIDS
- Diabetes
- Malignancies
- Nutritional deficiencies
Clinical presentation of OPC
- cottage cheese appearing plaques
- painful mouth, burning tongue, metallic taste
Clinical Presentation of EC
- painful and difficulty swallowing
- fever, few white/ beige plaques
Topical treatment for mild OPC
- treat for 7-14 days
- clotrimazole 10mg troche 5xday
- Nystatin 5mL swish and swallow
- Miconazole 50mg buccal tablet
Systemic treatment for refractory OPC patients who can’t tolerate or respond to mild therapy
- FLuconazole Daily
- Itraconazole solution Daily
- Posaconazole daily for 14 days
Treatment for Fluconazole-Refractory OPC
treat from 14-28 days
- itraconazole daily
- posaconazole suspension for 28 days
- Amphotericin B deoxycholate
- Voriconazole
- Caspofungin
- Micafungin
- Anidulafungin
- Amphotericin B deoxycholate
Treatment of Esophageal Candidiasis
treatment 14-21 days
- fluconazole
- itraconazole
- echinocandin
- voriconazole
- posaconazile
- amphotericin B
- Fluconazole refractory treat for 21-28 days
- higher dose itraconazole
- caspofungin
- micafungin
- anidulafungin
Vulvovaginal candidiasis is
- an infection in women with or without symptoms who have positive vaginal cultures
Complicated versus uncomplicated vulvovaginal candidiasis
uncomplicated - sporadic infection susceptible to all anti fungal therapy
complicated - recurrent VVC severe disease; non-candida albicans infection
Candida albicans and its role in VVC
- responsible for the overwhelming majority of VVC
- C. glabrata is increasing in frequency
- terminated candida associated with tissue invasion
VVC Risk factors
- contraceptives
- antibiotic use
- increased incidence in post-menopausal women taking HRT
VVC Symptoms
- intense culcular itching, burning on urination
- curl cheese like discharge
- test for vaginal pH
VVC Treatment
- Over the counter topical agents for uncomplicated VVC are butoconazole, clotrimazole, miconazole, tioconazole.
- prescription Uncomplicated VVC Nystatin and Terconazole, fluconazole, ibrecafangerp
Complicated VVC Treatment
treatment duration 10-14 days and use the same drugs
- topical agents are safe throughout pregnancy, oral agents contraindicated.
Recurrent VVC Treatment
Two stage treatment with Topical or oral azole 10-14 days followed by fluconazole once a week for 6 months
Antifungal Resistance VVC
- Boric acid 600mg capsule, intravaginally daily, then 1 capsule twice a week
- FLucytosine cream 1000mg
Dermatophytoses is a superficial mycotic infection of
the skin
Typical organisms involved in Mycotic infections of ski, hair, and nails
TRICHOPHYTON, EPIDERMOPHYTON, MICROSPORUM
Risk factors for mycotic infections
prolonged exposures to sweaty clothes, failure to bathe regularly,skin folds
Tinea pedis
athletes foot
- topical treatment for 2-4 weeks is adequate in mild infections
Tinea manuum
- involves the palmar surfaces
Tinea cruris
jock itch topical therapy for mild infections
tine corporis
- infection of skin and trunk and extremities
tinea capitis
- involves scalp and hair
- usually affects children
- usually treated with oral therapy Terbinafin
tine barbae
infection of hair follicles on beards and mustache
tinea versicolor
- hyper or hypopigmented scaly patches on trink and extremities
- common for adults in tropical environments
- topical therapy usually enough
Topical agents that can be used for: Tinea Pedis Tinea mannum Tinea cruris Tinea corporis
- Butenafine
- Sertaconazole
- Ciclopirox
- Clotrimazole
- Econazole
- Haloprogin
- Ketoconazole cream
- Miconazole
- Oxiconazole
- Sulconazole
- Terbinafine
Oral agents that can be used for more severe infections of: Tinea Pedis Tinea mannum Tinea cruris Tinea corporis
- FLuconazole
- Itraconazole
- Terbinafine
Tinea capitis topical treatment
Shampo in conjunction with Terbinafine for 4-8 weeks
Tinea barbae topical treatment
- Ketoconazole
- Selenium Sulfide
Tinea barbae oral treatment
Itraconazole
Tinea versicolor topical treatment
- Clotrimazole
- Econazole
- Haloprogin
- Ketoconazole
- Miconazole
- Oxiconazole cream
- Sulconazole
Tinea versicolor oral treatment
- Fluconazole
- Itraconazole
onchyomycosis treatment
- Terbinafine
- Itraconazole
- Fluconazole
Terbinafine AE
- Potent inhibitor of CYP2D6,
- rare and severe hepatotoxicity avoid in liver disease
- may decrease lymphocyte count
Histoplamosis potpurri
- Ohio and Mississippi River Valley
- Caused by Histoplasma capsulatum
- organism is phagocytized by macrophages but not killers, macrophages migrate to other areas
Histoplasmosis and granulomas
- granulomas form to wall off organism and causes necrotic degredation of tissue
- granulomas become encapsulated and calcified over several years with viable organisms still trapped. can become reinfected if immune system wanes
Histoplasmosis presentation
- variable degree of immune suppression
- low inoculum can result in mild pulmonary infection
- high innoculum can result in flu-like sympoms and become hypoxic
Disseminated histoplasmosis
- seen in immunocompromised or high innoculum where the body cannot form granulomas
- go through asymptomatic periods and then have periods of weakness and fatigue
Histoplasmosis Diagnosis
- standard is serological testing
Acute Histoplasmosis Treatment in immunocompetent hosts
- Mild/moderate disease
Itraconazole 6-12 weeks (also posaconazole or fluconazole_ - Moderately Severe Disease
Lipid Amphotericin B for 12 weeks, (may use deoxycholate if low nephrotoxic risk), and methylprednisolone
Disseminated Histoplasmosis treatnment in an immunocompromised host
- Less severe disease
Itraconazole for 12 weeks (posaconazole, voriconazole, or fluconazole are ok substitutes) - Moderately severe disease
Lipid amphotericin B for 1-2 weeks, then Itraconazole for 12 months
Blastomyces dermatitides potpurri
- endemic to south eastern south centeral and midwest united states
- infection occurs after inhalaion of the conidia, this draws neutrophils to the lungs and then disseminates it through the body and forms granulomas
Acute pulmonary blastomycosis symptoms
- fever chills and productive cough in immunocompetent host
Chronic pulmonary blastomycosis symptoms
- fever, malaise, weight loss, night sweats, chest pain, and productive cough
Treatment of pulmonary blastomycosis in immunocopetent patients
- mild-moderate disease
itraconazole for 6 months - moderately severe-severe disease
lipid amphotericin B for 1-2 weeks then itraconazole for 6-12 months
Disseminated or extrapulmonary Blastomycosis in immunocompetent patients
- CNS disease
induction lipid amphotericin B 4-6 weeks followed by oral azole for at least 12 months (fluconazole, voriconazolem or itraconazole) - Moderately severe and mild to moderate disease treat the same as pulmonary disease
Blastomycocis treatment in immunocompromised host
- Acute disease
Lipid amphotericin B for 1-2 weeks until improvement and then suppressive therapy for at least 12 months
Itraconazole for at least 12 months - suppressive therapy might be considered for lifelong patients that we cannot reverse immunocuppression
coccidiodomycosis potpurrie
- endemic in southwestern and western united states
- causative pathogen is coccidiodes immits
- initial infection almost always involves lungs
Primary coccidiodomycosis facts
- valley fever
- symptoms are fever, cough, headache, sore throat and arthralguas and myalgias, diffuse macropapular rash appears in a few days, pneumonia can be seen later with a blood streaked cough
coccidiodomycosis clinical presentation
- persistent pulmonary coccidiodomycosis
disease last more than 6 weeks and is complicated by scarring and spiting blood - disseminated coccidiodomycosis
seen in skin, lymph nodes, bone, CNS infections we can see headache weakness, neck stiffness, and low grade fever
coccidiodomycosis treatment
- primary respiratory infection
fluconazole and itraconazole for 3-6 months - symptomatic chronic cavitary pneumonia
fluconazole and itraconazole - diffuse pneumonia with bilateral or miliary infiltrates
disseminated coccidiodomycosis treatment
- nonmeningeal disease
itraconazole or fluconazole, or amphotericin B - meningeal disease
choice treatment is fluconazole for lifelong suppresivetherapy, other options include itraconazole or intrathecal amphotericin B
Cryptococcus potpurri
- Cryptococcus neoformans found more in immunocompromised hosts
- Cryptococcus gattii more in immunocompetent hosts.
- found in soil and pigeon droppings
- cell mediated immunity plays important role in this
Cryptococcus Clinical Presentation
- pulmonary cough, rales, SOB - Meningitis Non-Aids: photophobia, neck stiffness HIV/AIDS: Fever, malaise, headache
Cryptococcal meningitis treatment
- non-HIV, non-transplant host
induction: L amphotericin deoxycholate + flucytosine for 4 weeks, may use lipid amphotericin B, extend amphotericin to minimum of 6 weeks if neurologic conditions worsen or if there is no flucytosine given. consider 2 week duration for induction if low risk for failure
consolidation: fluconazole for 8 weeks
Maintenance: fluconazole for 6-12 months - HIV infected agents
Induction: liposomal amphotericin B + flucytosine for a minimum of 4 weeks,
Consolidation: fluconazole 8 weeks
Maintenance: minimum of at least 1 year of azole therapy. consider stopping after a year if CD4 count is greater than or equal to 100 cells and undetectable viral load for 3 months
Cryptococcal meningitis for HIV infected patients alternative regimens
- amphotericin deoxycholate or lipid amphotericin B for 4-6 weeks
- amphotericin B plus fluconazole for 2 weeks then fluconazole for 8 weeks
- fluconazole + flucytosine for 6 weeks
- fluconazole for 10-12 weeks
Cryptococcal meningitis treatment for organ transplant recipients
- Induction: Liposomal amphotericin B + flucytosine for at least 2 weeks
Consolidation: FLuconazole for 8 weeks
Maintenacne fluconazole for 6-12 months
Candidiasis potpurri
- C. albicans is the most common cause of invasive fungal infections
- PMNs play a major role in patients host defense
Candidiasis and candidemia presentation
- acute onset of fever, tachycardia, chills and hypotension
Candidemia Treatment in nonneutropenic adults
- Eichinocandins recommended as initial therapy (may transition later to fluconazole if susecptible)
- FLuconazole daily for patients who are unlikely to have fluconazole-resistant Candida species
- azole susceptibility testing recommended for all clinically relevant isolates
- alternative therapy is Lipid amphotericin B, or voriconazole, remove catheters if possible. treat for 14 days after negative blood culture
Candidemia treatment in neutropenic adults
- eichinocandin recommended as initial therapy
- lipid formulation of amphotericin B
- if not critically ill and no prior azalea exposure use fluconazole or voriconazole
pathogen specific treatments candidemia in neutropenic adults
C. glabrata - echinocandin
C. parapsilosis - fluconazole or lipid amphotericin B
C. krusei - eichinocandin, lipid amphotericin B or voriconazole preferred
- treat for 14 days after documented clearance of candida from blood, resolution of symptoms and neutropenia. remove IV catheters
Chronic Disseminated candidiasis treatment
- lipid amphotericin B or an eichinocandin for several weeks, followed by fluconazole
- continue therapy until documentation fo lesion resolution on repeat
Empiric Treatment of suspected invasive candidiasis in nonneutropenic adults in ICU
- eichinocanfin preferred
- alternative regimens fluconazole in patients who are not colonized with an azalea resistant Candida species
- recommended treatment duration is 2 weeks
Empiric treatment of suspected invasive candidiasis in neutropenic adults in the ICU
- lipid amphotericin B
- echinocadin
- voriconazole
- alternative agents
fluconazole, itraconazole - azalea should not be used in patients who have received azalea for prophylaxis
prophylaxis of invasive candidiasis in the ICU treatment
- fluconazole in patients in ICUs greater than 5% 0f invasive candidiasis
- echinocandin is an alternative
- daily bathing with chlorhexidine
intraabdomnial candidiasis treatment
- consider empiric anti fungal therapy for patients with clinical evidence of an intra-abdominal infection, treatment the same as candidiasis in nonneutropenic adults
growth of candida species from respiratory secretions, does it require anti fungal therapy
no it doesn’t
symptomatic treatment of candida UTIs
- for fluconazole susceptible candida cystitis, fluconazole for 2 weeks
- for fluconazole resistant candida species amphotericin B deoxycholate for 1-7 days. amphotericin bladder irrigation. flu cytosine 7-10 days.
- remove or replace indwelling catheters
aspergillus potpurri
- causative pathogens are, A. fumigatus, A. flavus, A. niger, A. terries and generally acquired by conidia
- impaired host defenses are required for development of invasive disease. prolonged neutropenia is the most important predisposing factor
aspergillosis clinical presentation
- commonly presents in the lungs
- survival beyond 2 or 3 weeks is uncommon, chest pain
- hyphae invade walls of bronchi and surrounding parenchyma resulting in necrotization
aspergillus diagnosis
- based on septate hyphae
treatment of aspergillosis in invasive pulmonary aspergillosis
- voriconazole
- lipid amphotericin, isavuconazole plus echinocandin in select patients
- echinocandin primary therapy not recommended
- therapy recommended for 6-12 weeks
invasive pulmonary aspergillosis salvage therapy treatment options
- amphotericin B, Caspofungin, Micafungin, Posaconazole, or itraconazole
prophylaxis of aspergillosis
- posaconazole primary
- alternative agents are voriconazole, itraconazole, micafungin. aerosilized amphotericin B
