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Therapeutics V > Superficial and Invasive Fungal Infections > Flashcards

Superficial and Invasive Fungal Infections Flashcards

1
Q

Most common causes of fungal infections

A

Aspergillus, candida and pneumocystis

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2
Q

Most common Candida (oropharyngeal, OPC, and esophageal, EC)

A

Candida albicans

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3
Q

Candidiasis is an ______________ infection

A

opportunistic infection

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4
Q

Candidiasis is what type of immunity

A

cell-mediated (mediated by CD4 T-cells)

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5
Q

OPC & EC Risk Factors (local)

A

-Use of steroids (suppress cellular immunity) and
antibiotics (alteration of endogenous oral flora)

-Dentures

-Xerostomia due to drugs, chemotherapy,
radiotherapy to head/neck, BMT

-Smoking

-Disruption of oral mucosa caused by chemotherapy
and radiotherapy, ulcers, endotracheal intubation
trauma, burns

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6
Q

OPC Clinical presentation

A

“cottage cheese appearance”

yellow-ish white

scrapes off easily

dysphagia (difficulty swallowing)

odynophagia (pain on swallowing)

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7
Q

OPC & EC Risk Factors (systemic)

A

-Drugs (e.g., cytotoxic agents, corticosteroids,
immunosuppressants after organ transplantation,
PPIs)

-Neonates or elderly

  • HIV infection/AIDS
  • **Depletion of CD4 T-lymphocytes
  • **HIV viral load
  • Diabetes
  • Malignancies (e.g., leukemia, head/neck cancers)
  • Nutritional deficiencies
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8
Q

OPC treatment range

A

7 - 14 days

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9
Q

OPC: mild infection

A

topical

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10
Q

OPC: MILD tx options (3)

A

-Clotrimazole 10 mg troche (hold in mouth for 15-20
minutes for slow dissolution) 5x/day

-Nystatin 100,000 units/ml suspension, 5 mL swish and
swallow, QID

  • Miconazole 50 mg mucoadhesive buccal tablet, apply to upper gum region (canine fossa) daily x 7-14 days
  • **Apply in morning after brushing teeth; hold in place 30 seconds to ensure adhesion; gradually dissolves
  • **Eat and drink normally but avoid chewing gum
  • **If falls off & swallowed in first 6 hours, apply new tablet
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11
Q

OPC: Mild

WHY WOULD USE SYSTEMIC THERAPY

A

Systemic therapy needed in patients with
refractory OPC, patients who cannot tolerate
topical agents, patients with moderate to severe
disease, and patients at high-risk for
disseminated systemic disease (neutropenia)

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12
Q

OPC Mild systemic therapy

A

*Fluconazole (most common) 100-200 mg daily (preferred)

  • Itraconazole solution 200 mg daily
  • **Take on empty stomach

-Posaconazole suspension 100 mg BID on day 1, then
100 mg daily x 14 days (with food)

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13
Q

OPC Mild systemic therapy IF REFRACTORY, how long treat

A

> /= 14 days

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14
Q

OPC Mild systemic therapy refractory treatment options

A

(options if can’t use fluconazole)

  • Itraconazole solution 200 mg daily
  • Posaconazole suspension 400 mg BID x 3 days, then 400 mg
    daily for 28 days
  • Amphotericin B deoxycholate suspension (100 mg/mL) 1-5 mL
    swish & swallow QID
  • Voriconazole 200 mg BID (> 40 kg)
  • Caspofungin 70 mg LD, then 50 mg IV daily
  • Micafungin 150 mg IV daily
  • Anidulafungin 200 mg IV daily
    • Amphotericin B deoxycholate 0.3-0.7 mg/kg/day
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15
Q

EC candidiasis tx length of time

A

14 - 21 days

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16
Q

EC candidiasis tx options

A

Systemic therapy always required

• Fluconazole 200-400 mg PO/IV daily
• Itraconazole solution 200 mg PO daily
• Echinocandin (micafungin 150 mg daily; caspofungin 70 mg
LD, then 50 mg daily; anidulafungin 200 mg daily)
• Voriconazole 200 mg PO/IV BID (> 40 kg)
• Posaconazole suspension 400 mg PO BID or delayed release
tablets 300 mg daily
• Amphotericin B deoxycholate 0.3-0.7 mg/kg/day

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17
Q

For EC candidiasis, always

A

SYSTEMIC THERAPY

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18
Q

EC candidiasis refractory

A
  • Fluconazole-refractory – treat for 21-28 days
  • Itraconazole solution 200 mg PO daily
  • Posaconazole suspension 400 mg PO BID (with food)
  • Voriconazole 200 mg PO/IV BID (> 40 kg)

• Amphotericin B deoxycholate 0.3-0.7 mg/kg/day or
lipid-based formulation 3-5 mg/kg/day

  • Caspofungin 50 mg IV daily
  • Micafungin 150 mg IV daily
  • Anidulafungin 100 mg IV on day 1, then 50 mg IV daily
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19
Q

vulvovaginal candidiasis (VVC): complicated vs uncomplicated

A
  • Uncomplicated: sporadic infection that is susceptible to all
    forms of antifungal therapy regardless of treatment duration
  • Complicated: recurrent VVC; severe disease; non-Candida
    albicans infection; host factors (DM, immunosuppression,
    pregnancy)
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20
Q

VVC most common pathogen

A

Candida albicans

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21
Q

VVC non-c albicans, next most common

A

C. glabrata most common

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22
Q

If female complains of burning…

A

ask more questions regarding infection

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23
Q

pseudohyphae

A

THINK CANDIDA, THEN THINK SEGMENTED OR NON-SEGMENTED

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24
Q

VVC tx topical vs oral

A

topical // oral = cure rates are similar

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25
Q

VVC tx duration

A

***duration not critical

-Similar cure rates despite different lengths of therapy
-Shorter durations (e.g., 1 day) have higher drug
concentrations that maintain therapeutic effect for 72
hours

26
Q

Uncomplicated VVC tx (OTC/topical vaginal products)

A
  • Butoconazole 2% cream, 1 applicator x 3 days
  • Clotrimazole
  • **1%, 2%, 10% cream, 1 applicator x 1 day
  • **100 mg tablet, 1 tablet x 7 days
  • **200 mg tablet, 1 tablet x 3 days
  • **500 mg tablet, 1 tablet x 1 day
  • Miconazole
  • **2% cream, 1 applicator x 1 day
  • **100 mg suppository, 1 suppository x 7 days
  • **200 mg suppository, 1 suppository x 3 days
  • **1200 mg ovule, 1 ovule x 1 day

-Tioconazole 6.5% cream, 1 applicator x 1 day
• Prescription/topical

-Nystatin 100,000 units tablet, 1 tablet x 14 days

(FIX THIS)

  • Terconazole
  • **0.4% cream, 1 applicator HS x 7 days
  • **0.8% cream, 1 applicator HS x 3 days
  • **80 mg suppository, 1 suppository HS x 3 days
27
Q

Uncomplicated Prescription/oral

A
  • Fluconazole 150 mg tablet, 1 tablet PO x 1 day

- Ibrexafungerp 300 mg PO twice daily x 1 day

28
Q

GO BACK AND REDO TX SLIDES

A

GO BACK AND REDO TX SLIDES

29
Q

How is boric acid given?

A

GIVE INTRAVAGINALLY

30
Q

Tinea capitis

A

More common in children

31
Q

Define prophylaxis

A

pt not infected, want to prevent from getting infected

32
Q

Histoplasmosis onset

A

specific T-cell immunity in non-immune host

33
Q

What is a granuloma?

A

area of tissue inflammation due to a
collection of immune cells; form when immune
system attempts to wall off foreign substances but
can’t eliminate it (need functional T-cells to form this)

34
Q

Histoplasmosis Clinical Presentation: Disseminated histoplasmosis

A

May be seen in patients exposed to large inoculum or in immunocompromised host (especially if decreased ***cell-mediated immunity)

35
Q

Histoplasmosis Diagnosis

A 
Serologic testing – detect Histoplasma antigen (blood,
urine, BAL)
- Complement fixation
- Immunodiffusion
- Latex agglutination
36
Q 
HISTOPLASMOSIS TREATMENT –
IMMUNOCOMPETENT HOST (can cause disease in a NORMAL host)
A

most of the time asymptomatic

37
Q

What is the DRUG OF CHOICE histoplasmosis? (FOR MILD TO MODERATE)

A

FUCKING itraconazole (weeks for duration of therapy)

also keep in mind subaitraconazole

also think about tablet and capsule formulations

38
Q

What is the DRUG OF CHOICE histoplasmosis? (FOR MODERATE TO SEVERE)

A

lipid amphotericin B deoxycholate

39
Q

How to differentiate between mild-moderate and moderate to severe histoplasmosis disease?

A

Disease severity

40
Q 
HISTOPLASMOSIS TREATMENT –
IMMUNOCOMPROMISED HOST (can cause disease in a NORMAL host)
A

Re listen to his comments

41
Q

clarify tx durations for immunocompetent vs immunnocompromised

42
Q

if case of pt in arizona or new mexico, what is the organism

A

coccidioimycosis

coccidioides immitis

43
Q

if see diffuse maculopapular rash

A

think coccidioimycosis

44
Q

go back and match states/region to pathogen

A

i.e. histo = indiana

45
Q

cryptococcosis what type of immunity

A

cell-mediated immunity

46
Q

flucytosine SE

A

bone marrow suppression

47
Q

candida loves what

A

FUCKING PLASTIC

48
Q

CANDIDIASIS/CANDIDEMIA

PATHOPHYSIOLOGY/CLINICAL PRESENTATION: What plays a major role?

A

PMNs (polymorphonuclear i.e. neutrophils, eosinophils, basophils) play a major role in patient’s host defense

49
Q

Would use voriconazole for candidemia in nonneutropenic adults?

A

no we got other stuff

50
Q

For candidemia, clock doesn’t start

A

until there is a negative blood culture. That day is day one** (double check this)

51
Q

CANDIDEMIA – TREATMENT

NEUTROPENIC ADULTS: C. glabrata

A

echinocandin preferred

52
Q

If C. krusei – echinocandin, lipid amphotericin B,

or voriconazole preferred

A

DO NOT FUCKING USE FLUCONAZOLE

53
Q

CANDIDEMIA – TREATMENT

NEUTROPENIC ADULTS: C. parapsilosis

A

fluconazole or lipid

amphotericin B preferred

54
Q

Do NOT treat candida

A

from a sputum culture

55
Q

How long treat candida?

A

Treat for 14 days after documented clearance of
Candida from blood, resolution of symptoms,
and resolution of neutropenia

NEED PATHOLOGIC EVIDENCE OF CONTAMINATION

56
Q

Do you treat asymptomatic candiduria?

A

FUCKING NO

57
Q

WHAT GETS INTO THE URINE?

A

FLUCONAZOLE AND FLUCYTOSINE

58
Q

ASPERGILLOSIS MOST COMMON PATHOGEN

A

A. fumigatus

59
Q

ASPERGILLIUS…DONT USE

A

AMPHOTERICIN

60
Q

_____________ is the most important
predisposing factor to the development of
invasive aspergillosis

A

PROLONGED NEUTROPENIA

61
Q

ASPERGILLOSIS

CLINICAL PRESENTATION most common site

62
Q

if see halo sign on ct think

A

aspergillus

Therapeutics V (17 decks)

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