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Spring 2022: Therapeutics IV > Superficial Fungal Infections (Kays) > Flashcards

Superficial Fungal Infections (Kays) Flashcards

1
Q

Thrush involves infection of the ______________.

A

oral mucosa

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2
Q

What bacteria is most commonly implicated in oropharyngeal and esophageal candidiasis?

A

C. albicans

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3
Q

What is the most common opportunistic infection in HIV patients?

A

oropharyngeal candidiasis

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4
Q

What is the primary line of host defenses against superficial Candida infections?

A

cell-mediated immunity (mediated by CD4 T-cells)

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5
Q

What are the local risk factors for OPC and EC?

A
  • steroid/antibiotic use
  • dentures
  • xerostomia due to drugs, chemotherapy, head/neck radiotherapy, BMT
  • smoking
  • disruption of oral mucosa from chemotherapy, radiotherapy, ulcers, endotracheal intubation, trauma, burns
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6
Q

Why is steroid use considered a local risk factor for OPC and EC?

A

steroids suppress cellular immunity

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7
Q

Why is antibiotic use considered a local risk factor for OPC and EC?

A

antibiotics can alter the endogenous oral flora

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8
Q

What are the systemic risk factors for OPC and EC?

A
  • drugs (cytotoxic agents, corticosteroids, immunosuppressants after organ transplant, PPIs)
  • neonate or elderly
  • HIV/AIDS
  • diabetes
  • malignancies (leukemia, head/neck cancers)
  • nutritional deficiencies
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9
Q

What about HIV/AIDS infections are risk factors for OPC and EC?

A
  • they cause depletion of CD4 T-lymphocytes
  • HIV viral load
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10
Q

A patient presents with cottage cheese-like, yellowish-white, soft plaques overlying areas of erythema on the buccal mucosa, tongue, gums, and throat. What is the most likely diagnosis?

A

oropharyngeal candidiasis (OPC)

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11
Q

OPC plaques are easily removed by _______________.

A

vigorous rubbing

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12
Q

Although some patients may experience no OPC symptoms, which noticeable ones may occur?

A
  • painful mouth
  • burning tongue
  • metallic taste
  • dysphagia
  • odynophagia
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13
Q

What are the three most common symptoms that an esophageal candidiasis (EC) patient may present with?

A
  • dysphagia
  • odynophagia
  • retrosternal chest pain
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14
Q

True or false: esophageal candidiasis patients can present with fever.

A

true

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15
Q

Esophageal candidiasis plaques can be _________ or _________ with ulceration in severe cases.

A

hyperemic; edematous

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16
Q

How do we diagnose esophageal candidiasis?

A

upper GI endoscopy with biopsy

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17
Q

What is the recommended treatment duration for oropharyngeal candidiasis?

A

7-14 days

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18
Q

What are the recommended topical therapies for mild OPC?

A
  • clotrimazole troche 5x day
  • nystatin suspension (5 mL swish and swallow) QID
  • miconazole mucoadhesive buccal tablet (applied to upper gum region) daily x 7-14 days
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19
Q

How long should a clotrimazole troche be held in the mouth for slow dissolution?

A

15-20 minutes

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20
Q

What counseling points would you give a patient taking miconazole buccal tablets for OPC?

A
  • apply in the morning after brushing teeth, and hold in place for 30 seconds to ensure adhesion; will gradually dissolve
  • don’t chew gum
  • if the tablet falls off and is swallowed within the first 6 hours, apply a new tablet
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21
Q

In which OPC patients may systemic therapy be required?

A
  • refractory OPC
  • unable to tolerate topicals
  • moderate-to-severe disease
  • high risk for disseminated systemic disease (neutropenia)
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22
Q

What are the systemic treatment options for OPC?

A
  • fluconazole QD (preferred)
  • itraconazole solution daily
  • posaconazole suspension BID on day 1, then QD x 14 days
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23
Q

Which systemic OPC agent should be taken on an empty stomach?

A

itraconazole solution

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24
Q

Which systemic OPC agent should be taken with food?

A

posaconazole suspension

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25
Q

What is the recommended treatment duration for fluconazole-refractory OPC?

A

≥ 14 days (up to 28 days)

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26
Q

What treatment regimens are recommended for fluconazole-refractory OPC?

A
  • itraconazole solution QD
  • posaconazole suspension BID x 3 days, then QD for 28 days
  • voriconazole BID (> 40 kg)
  • amphotericin B deoxycholate suspension 1-5 mL swish & swallow QID
  • amphotericin B deoxycholate 0.3-0.7 mg/kg/day
  • caspofungin LD, then IV daily
  • micafungin IV daily
  • anidulafungin IV daily
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27
Q

What is the recommended treatment duration for esophageal candidiasis?

A

14-21 days

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28
Q

True or false: topical therapies are an option for treating esophageal candidiasis.

A

false; systemic therapy is ALWAYS required

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29
Q

What treatment regimens are recommended for esophageal candidiasis?

A
  • fluconazole PO/IV daily
  • itraconazole solution PO daily
  • voriconazole PO/IV BID (> 40 kg)
  • posaconazole suspension BID or delayed release tablets daily
  • echinocandin (micafungin daily; caspofungin LD, then daily; anidulafungin daily)
  • amphotericin B deoxycholate 0.3-0.7 mg/kg/day
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30
Q

What is the recommended duration of treatment for fluconazole-refractory esophageal candidiasis?

A

21-28 days

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31
Q

What are the recommended treatment regimens for fluconazole-refractory esophageal candidiasis?

A
  • posaconazole suspension PO BID (with food)
  • voriconazole 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 IV daily
  • micafungin IV daily
  • anidulafungin IV on day 1, then IV daily
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32
Q

Vulvovaginal candidiasis can be classified as ________ or _______ depending on frequency.

A

sporadic; recurrent

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33
Q

Define uncomplicated vulvovaginal candidiasis.

A

sporadic infection that is susceptible to all forms of antifungal therapy regardless of treatment duration

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34
Q

Define complicated vulvovaginal candidiasis.

A

recurrent VVC; severe disease; non-Candida albicans infection; host factors (DM, immunosuppression, pregnancy)

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35
Q

What organism is responsible for 80-92% of symptomatic VVC?

A

C. albicans

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36
Q

What is the most common non-C. albicans organism for VVC?

A

C. glabrata

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37
Q

_________ species are dimorphic.

A

Candida

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38
Q

____________ are responsible for Candida colonization (transmission and spread).

A

blastospores

39
Q

_______________ Candida forms are associated with tissue invasion and symptomatic infection.

A

germinated

40
Q

What the risk factors for vulvovaginal candidiasis?

A
  • sexual activity
  • oral-genital contact
  • contraceptive agents (diaphragm with spermicide, sponge, IUD)
  • high-dose oral contraceptives
  • antibiotic use
  • post-menopausal women taking HRT
41
Q

What symptoms are associated with vulvovaginal candidiasis?

A
  • intense vulvar itching
  • soreness
  • irritation
  • burning on urination
  • dyspareunia
42
Q

What signs are associated with vulvovaginal candidiasis?

A
  • erythema
  • fissuring
  • curdy cheese-like discharge
  • satellite lesions
  • edema
43
Q

Someone with VVC will have a _______ vaginal pH.

A

normal

44
Q

In VVC patients, saline and KOH microscopy will reveal what two results?

A

blastospores or pseudohyphae

45
Q

In VVC, cultures for Candida are not recommended…except in which two cases?

A
  • classic signs/symptoms with normal vaginal pH and microscopy are inconclusive
  • suspected recurrence
46
Q

What patient education can you give for VVC?

A
  • avoid harsh soaps/perfumes that can cause or worsen vulvar irritation
  • keep genitals clean and dry
  • cool baths can soothe the skin
  • douching is not recommended for prevention or treatment
  • oral lactobacillus (controversial)
47
Q

What is one of the major disadvantages of using topical azoles for uncomplicated VVC?

A

topical preparations can decrease efficacy of latex condoms and diaphragms

48
Q

Which has the higher cure rate in uncomplicated VVC: topical/oral azoles, or nystatin?

A

topical/oral azoles (80-95%)

49
Q

True or false: topical therapy is therapeutically superior to oral therapy for VVC.

A

false; oral and topical therapy are therapeutically equivalent

50
Q

What OTC topicals can be used for uncomplicated VVC?

A
  • butoconazole 2% cream x 3 days
  • clotrimazole 1/2/10% cream x 1 day
  • clotrimazole tablet x 1, 3, or 7 days
  • miconazole 2% cream x 1 day
  • miconazole suppository x 3, 7 days
  • miconazole ovule x 1 day
  • ticonazole 6.5% cream x 1 day
51
Q

What prescription topicals can be used for uncomplicated VVC?

A
  • nystatin x 14 days
  • terconazole cream x 3, 7 days
  • terconazole suppository x 3 days
52
Q

What prescription oral medications can be used for uncomplicated VVC?

A
  • fluconazole x 1 day
  • ibrexafungerp x 1 day
53
Q

What is the recommended duration of therapy for complicated VVC?

A

10-14 days (regardless of route of administration)

54
Q

How far apart should fluconazole doses be spaced in complicated VVC?

A

72 hours

55
Q

What treatment options are contraindicated for complicated VVC in pregnancy?

A

oral agents; concern for fetal complications

56
Q

What is the preferred treatment regimen for complicated VVC in pregnancy?

A

topical azole x 7 days

57
Q

What would qualify a patient as having recurrent VVC?

A

> 4 episodes within a 12-month period

58
Q

What is the recommended treatment regimen for recurrent VVC?

A

topical/oral azole x 10-14 days, then fluconazole PO once a week x 6 months

59
Q

When should you consider whether a patient’s VVC may be antifungal-resistant?

A

if persistently positive yeast cultures and/or failure to respond to therapy despite adherence

60
Q

What are the recommended treatment regimens for antifungal-resistant VVC?

A
  • boric acid capsule intravaginally daily x 14 days, then twice a week
  • flucytosine cream intravaginally nightly x 7 days
61
Q

What are superficial mycotic infections of the skin called?

A

dermatophytoses

62
Q

What are the risk factors for superficial mycotic infections?

A
  • prolonged exposure to sweaty clothes
  • failure to regularly bathe
  • many skin folds
  • sedentary
  • confined to bed
63
Q

What is preferred for treating mild tinea pedis: topical or oral therapy?

A

topical

64
Q

What is the preferred duration of therapy for mild tinea pedis infection?

A

2-4 weeks

65
Q

Why is prolonged therapy required to treat tinea pedis?

A

because recurrence is so common

66
Q

What does tinea manuum involve?

A

palmar surfaces

67
Q

Tinea manuum treatment is similar to __________ treatment.

A

tinea pedis

68
Q

What area of the body does tinea cruris involve?

A

proximal thighs and buttocks (“jock itch”)

69
Q

What is the the recommended duration of therapy for tinea cruris?

A

1-2 weeks after symptoms resolve

70
Q

Which is generally preferred for tinea cruris: topical or oral therapy?

A

topical (severe infections may require oral)

71
Q

Tinea corporis is an infection of the _______ and ___________.

A

trunk; extremities

72
Q

Treatment of tinea corporis is similar to treatment of ____________.

A

tinea pedis

73
Q

Tine capitis is an infection involving ___________________________.

A

the scalp, hair follicles, and adjacent skin

74
Q

What is preferred in the treatment of tinea capitis: oral or topical therapy?

A

oral

75
Q

What is the preferred treatment regimen for tinea capitis?

A

terbinafine daily x 4-8 weeks

76
Q

What counseling point would you give to a tinea capitis patient?

A

use clean combs and brushes

77
Q

Tinea barbae is an infection of the ______________.

A

hairs and follicles of the beard and mustache

78
Q

Tinea barbae treatment is the same as ___________.

A

tinea capitis

79
Q

If someone has tinea barbae, what non-pharmacologic recommendation would you make?

A

shave the beard/mustache

80
Q

What is tinea (pityriasis) versicolor?

A

hyper- or hypopigmented scaly patches on the trunk and extremities

81
Q

Tinea versicolor is most common in adults and which environment?

A

tropical

82
Q

In tinea versicolor, ___________ therapy is adequate unless there is an extensive skin area or recurrent infection.

A

topical

83
Q

Tinea unguium is also known as _________.

A

onychomycosis

84
Q

Tinea unguium is an infection of the _________.

A

nails

85
Q

What are the risk factors for onychomycosis?

A
  • increasing age (especially > 40)
  • family history/genetic factors
  • immunodeficiency
  • diabetes
  • psoriasis
  • PVD
  • smoking
  • tinea pedis
  • frequent nail trauma
  • sporting activities (swimming)
86
Q

What are the recommended treatment regimens for tinea unguium of the fingernails?

A
  • terbinafine x 6 weeks
  • itraconazole x 1 week/month for 2 months
  • fluconazole for x 6+ months
87
Q

What are the recommended treatment regimens for tinea unguium of the toenails?

A
  • terbinafine x 12 weeks
  • itraconazole x 12 weeks
  • fluconazole x 12 months
88
Q

Terbinafine is fungicidal against ___________.

A

dermatophytes

89
Q

What are the GI side effects associated with terbinafine?

A
  • diarrhea
  • dyspepsia
  • nausea
  • abdominal pain
90
Q

What dermatological side effects are associated with terbinafine?

A
  • rash
  • urticaria
  • pruritus
91
Q

True or false: terbinafine can cause headaches.

A

true

92
Q

Why should we monitor CBCs in patients taking terbinafine?

A

terbinafine may cause a transient decrease in lymphocyte count

93
Q

What rare side effect should be noted for terbinafine?

A

severe hepatotoxicity; AVOID IN LIVER DISEASE

94
Q

Terbinafine is a potent inhibitor of _______.

A

CYP2D6

Spring 2022: Therapeutics IV (12 decks)

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