Systemic fungal infections

Question 1

Signs/symptoms

Answer 1

Fever, chills
Tachycardia
Tachypnea
Hypotension

Question 2

Empiric treatment

Answer 2

1st line: Echinocandins
- micafungin 100 mg IV daily
- casofungin 70 mg IV loading, then 100 mg daily
- anidulafungin 200 mg IV loading, then 100 mg daily

2nd line: Fluconazole
- fluconazole 800 mg loading, then 400 mg daily

Question 3

Targeted

Answer 3

14 days from 1st negative culture

When?
- susceptibilities
- clinically stable
- negative repeat blood cultures q48h
- appropriate therapy for 48h
- choose most narrow agent–>fluconazole

REMOVE THE LINE

Question 4

Neutropenic empiric treatment

Answer 4

1st line: Echinocandins
- micafungin 100 mg daily
- casofungin 70 mg loading, then 100 mg daily
- anidulafungin 200 mg loading, then 100 mg daily

1st line: Liposomal amphotericin B 3-5 mg/kg/day
Alternative: fluconazole or voriconazole

Question 5

Disseminated Histoplasmosis

Answer 5

Who? Large inoculum or immunocompromised patients with decreased cell-mediated immunity

Symptoms: Fever, chills, fatigue, weight loss, night sweats, hepatosplenomegly,
cough, chest pain, dyspnea

CNS symptoms: fever, headache, seizure, mental status changes

Question 6

Histoplasmosis acute pulmonary treatment

Answer 6

Asymptomatic or mild-mod with symptoms < 4 weeks: no treatment

Mild-moderate with symptoms > 4 weeks:
- itraconazole 200 mg TID x 3, then 200 mg BID x 6-12 weeks

Moderate-severe:
- lipid amphotericin B 3-5 mg/kg/day x 2 weeks, then itraconazole 200 mg TID x 3, then 200 mg BID x 12 weeks

Question 7

Histoplasmosis disseminated treatment

Answer 7

Lipid amphotericin B 3-5 mg/kg/day x 2 weeks, then itraconazole 200 mg TID x 3, then itraconazole 200 mg BID x 12 months

Monitor trough of itraconazole > 1.5 but < 3

Question 8

Blastomycosis pulmonary treatment

Answer 8

Mild-moderate: itraconazole 200 mg TID x 3 days, then 200 mg BID x 6 months

Moderate-severe: lipid amphotericin B 3-5 mg/kg/day x 2 weeks or until improvement, then itraconazole 200 mg TID x 3 days, then 200 mg BID for 6-12 months

Question 9

Blastomycosis CNS treatment

Answer 9

Induction: Lipid amphotericin B 5 mg/kg/day x 4-6 weeks

Consolidation: itraconazole 200 mg BID-TID x 12 months

Question 10

Coccidioidomycosis primary pulmonary treatment

Answer 10

No treatment unless large inocula, severe, risk factors

Question 11

Coccidioidomycosis severe pulmonary

Answer 11

When?
- severe weight loss > 10%
- intense night sweats > 3 weeks
- infiltrates involving more than 1/2 of one lung or portions of both
- antibody titers > 1:16
- inability to work or symptoms > 2 months

Question 12

Coccidioidomycosis severe pulmonary treatment

Answer 12

Primary: fluconazole 400-800 mg x 3-6 months

Symptomatic chronic cavitary pneumonia: fluconazole 400-800 mg x 12 months

Diffuse pneumonia with bilateral infiltrates: amphotericin B followed by azole x 12 months

Question 13

Cryptococcosis HIV treatment

Answer 13

Inductions: amphotericin B 3-5 mg/kg/day + flucytosine 100 mg/kg/day x 4 weeks

Alternative:
- amphotericin B x 4-6 weeks
- amphotericin B + fluconazole
- fluconazole + flucytosine
- fluconazole

Consolidation: fluconazole 800 mg daily x 8 weeks

Maintenance: fluconazole 400 mg x 12 months

Question 14

Aspergillus prophylaxis

Answer 14

Posaconazole 300 mg q12h on day 1, then 300 mg daily

Alternative:
voriconazole
itraconazole
micafungin
amphotericin B