Systemic fungal infections Flashcards by Meghan Collins

What is candidiasis?

From the candida spp
-Yeast that are small and reproduce by budding

How well did you know this?

Not at all

Perfectly

Candida are normal flora of

Skin, female genital tract, and entire GI tract in humans

How well did you know this?

Not at all

Perfectly

____ is the most common invasive fungal infection (most are acquired endogenously)

Candidiasis

How well did you know this?

Not at all

Perfectly

An end site for candida is the ____

eye

How well did you know this?

Not at all

Perfectly

Candidiasis signs/symptoms

Fever
Tachycardia
Tachypnea
Chills
Hypotension

**Similar to bacteremia; hard to differentiate

How well did you know this?

Not at all

Perfectly

Candidiasis RF

-Broad-spectrum antibacterial agents bc killing off normal flora
-Use of central venous (CVC, PICC) and urinary catheters
-Received parenteral nutrition (TPN)
-Received hemodialysis & renal replacement tx in ICU pts
-Neutropenia (ANC < 500 cells/mm3)
-Use of implantable prosthetic device (Candida can adhere to these)
-Received immunosuppressive agents
-Surgery (especially inta-abdominal)
-Intra-abdominal perforation (gun shot; car accident)
-ICU length of stay

How well did you know this?

Not at all

Perfectly

Candidemia tx Preferred initial tx

Echinocandins
-Micafungin
-Caspofungin
-Anidulafungin

How well did you know this?

Not at all

Perfectly

Candidemia tx once susceptibilities are known

Fluconazole
Other azoles

How well did you know this?

Not at all

Perfectly

Recommended to get susceptibility testing done on all blood stream & clinically relevant isolates especially _____ and _____ due to variability in susceptibilities

C. glabrata
C. parapsilosis

How well did you know this?

Not at all

Perfectly

_____ has pretty good coverage across the spectrum

Micafungin

How well did you know this?

Not at all

Perfectly

Candidemia tx
-Narrow to oral tx

-Need susceptibilities
-Pts must be clinically stable
-Negative repeat blood cultures
-Been on appropriate tx for 48H
-Choose the most narrow agent (ideally fluconazole)

*REMOVE THE LINE bc candida like to stick to prosthetic material

-Repeat blood culture after 48H

x14 days after FIRST NEGATIVE blood cx

How well did you know this?

Not at all

Perfectly

Alternative candida tx (don’t use unless you have to)

Amphotericin B
Voriconazole

x14 days after FIRST NEGATIVE blood cx

How well did you know this?

Not at all

Perfectly

Candidemia tx in neutropenic pts

-MAY need broader tx due to exposure
-ECHINOCANDIN is initial tx
*Caspofungin
*Micafungin
*Anidulafungin

-Lipid formulation of amphotericin B

-If not critically ill and no prior azole exposure:
*Fluconazole
*Voriconazole

How well did you know this?

Not at all

Perfectly

Disseminated histoplasmosis clinical presentation
-Anything outside of the pulmonary system [moved on]

-May be seen in pts exposed to large inoculum or in immunocompromised host (esp if decreased cell mediated immunity)
-Successful containment of organism with macrophages may not occur –> may progress to granulomas
-Progressive illness is characterized by persistent yeast-filled macrophages and inability to form granulomas
-In patients living with HIV, disseminated histoplasmosis can occur as a direct result of initial infection or reactivation of a dormant focus

How well did you know this?

Not at all

Perfectly

Symptoms of disseminated histoplasmosis

Fever
Chills
Fatigue
-WEIGHT LOSS
-NIGHT SWEATS
-HEPATOSPLENOMEGALY (likes to go into liver)
-Cough; chest pain; dyspnea

How well did you know this?

Not at all

Perfectly

CNS histoplasmosis sx

Fever
HA
Seizure
Mental status change

How well did you know this?

Not at all

Perfectly

Histoplasmosis tx in immunocompetent host
-Acute pulmonary histoplasmosis
*Asx or mild-moderate disease with sx < 4 weeks

NO TX REQUIRED

How well did you know this?

Not at all

Perfectly

Histoplasmosis tx in immunocompetent host
-Acute pulmonary histoplasmosis
*Mild-mod disease with sx > 4 weeks

-Itraconazole x 6-12 weeks (DOC)

-Alternative
*Posaconazole
*Fluconazole

How well did you know this?

Not at all

Perfectly

Histoplasmosis tx in immunocompetent host
-Acute pulmonary histoplasmosis
*Moderately severe-severe disease

Lipid Amp B , then itraconazole x total of 12 weeks

Histoplasmosis tx in immunocompromised host
-Disseminated histoplasmosis
*less severe disease

Itraconazole
*monitor trough concentrations

Histoplasmosis tx in immunocompromised host
-Disseminated histoplasmosis
*Moderately severe-severe disease

Lipid amp B, then itraconazole x 12 MONTHS

Coccidioidomycosis when to treat

-Most pts with symptomatic primary pulmonary disease recover without tx
-Tx pts with large inocula, if they have a severe infection, or concurrent RF (HIV infection, organ transplant, pregnancy, high doses of CCS)

Coccidioidomycosis is considered a severe infection if …

-Weight loss (>10%), intense night sweats persisting > 3 weeks
-Infiltrates involving more than 1/2 of one lung or portions of both lungs
-Complement fixation antibody titers > 1:16
-Inability to work (extreme fatigue), or sx that persist > 2 months

Coccidioidomycosis tx
-Primary respiratory infection

Fluconazole x 3-6 mos (DOC)

Itraconazole x 3-6 mos

Coccidioidomycosis tx -Symptomatic chronic cavitary pneumonia

Fluconazole x 12 mos (DOC) Itraconazole x 12 mos

Coccidioidomycosis tx -Diffuse pneumonia with bilateral or miliary infiltrates

Amp B x several weeks followed by azole x 12 mos

What is cryptococcosis?

The other yeast infection besides Candida -MOST common in HIV pts -Causative pathogen: C. neoformans in immunocompromised host; C. gattii in immunocompetent host -Encapsulated yeast found in soil and pigeon droppings -Infection acquired by inhalation of the organism -- resists phagocytosis due to capsule -Cell-mediated immunity plays a major role in host defense against infection -Disease may be localized in the lungs or disseminate to other areas (CSF)

Cryptococcosis clinical presentation -Pulmonary

Cough Rales SOB

Cryptococcosis clinical presentation -Meningitis in pt without HIV

HA N/V Mental status change Nuchal rigidity Less common: photophobia, blurred vision, papilledema, seizures, hydrocephalus

Cryptococcosis clinical presentation -Meningitis in pt with HIV

Fever Malaise HA **Have less sx due to reduced immune system

Cryptococcosis diagnosis

Meningitis (most common presentation) -Perform lumbar puncture & look at fluid (increased CSF opening pressure, increased CSF WBC, decreased CSF glucose, increased CSF protein) -Positive CSF (and serum) cryptococcal antigen -Rapid diagnostics as well to detect DNA in blood and CSF -Cx (both LP and blood) -Reduced inflammatory response in HIV/AIDS with extremely high cryptococcal antigen titer

Cryptococcal meningitis tx in non-HIV infected, non-transplant host **Rare, so when it happens, it is severe --INDUCTION

Amp B deoxycholate + flucytosine **must clear infection before moving to consolidation

Cryptococcal meningitis tx in non-HIV infected, non-transplant host **Rare, so when it happens, it is severe --CONSOLIDATION

Fluconazole x 8 weeks

Cryptococcal meningitis tx in non-HIV infected, non-transplant host **Rare, so when it happens, it is severe --Maintenance

Fluconazole x 6-12 months

Cryptococcal meningitis tx in HIV infected **Rare, so when it happens, it is severe --INDUCTION

Lipid Amp B + Flucytosine x > 2 weeks

Cryptococcal meningitis tx in HIV infected **Rare, so when it happens, it is severe --CONSOLIDATION

Fluconazole x 8 weeks

Cryptococcal meningitis tx in HIV infected **Rare, so when it happens, it is severe --MAINTENANCE

Fluconazole x 1 year * May be stopped in pts with CD4 > 100, who have undetectable viral load on ART for > 3 months, and received at least 1 y of maintenance tx

Withhold ART if pt is ______ or _____

New HIV diagnosis or not on ART

Cryptococcal meningitis tx in HIV infected --INDUCTION **alternative regimens

Amp B or lipid amp B Amp B + fluconazole Fluconazole + flucytosine Fluconazole

What to monitor for patient on Amp B

BUN CBC Mg K

Hallmark dx for aspergillosis dx

Halo sign on CT scan

Aspergillosis tx for invasive pulmonary aspergillosis **DOC**

Voriconazole x 6-12 weeks

Aspergillosis tx for invasive pulmonary aspergillosis **alternative regimens**

Lipid Amp B Isavuconazole Voriconazole + echinocandin x 6-12 weeks

Aspergillosis prophylaxis tx **If going to get a transplant **DOC**

Posaconazole

Aspergillosis prophylaxis tx **If going to get a transplant **alternative regimens**

Voriconazole Itraconazole Micafungin Aerosolized amp B