Systemic Fungal Infections - Tieman Flashcards
Candidiasis Signs / Symptoms
- fever
- __ cardia
- __ pnea
- chills
- ___ tension
- tachycardia
- tachypnea
- hypotension
Similar to bacteremia! Hard to differentiate!
Candidiasis Risk Factors
- ___ -spectrum antibacterial agents
- Use of central venous (CVC, PICC) and urinary ___
- Receipt of ___
- Receipt of hemodialysis and renal replacement therapy in ICU patients
- ___ (ANC ≤ ___ cells/mm3)
- Use of implantable prosthetic devices
- Receipt of ___ agents
- Surgery (especially ___ )
- Intrabdominal ___
- ICU length of stay
- broad
- catheters
- TPN
- neutropenia, 500
- immunosuppressive
- intrabdominal
- perforation
Candidemia Treatment
___ (tends to be preference until you know which species)
* Micafungin 100mg IV daily
* Caspofungin 70mg IV loading dose, then 50mg daily
* Anidulafungin 200mg IV loading dose, then 100mg daily
___ - 800mg load, then 400mg po or IV daily
- Use once you know species (base on local susceptibilities)
Recommended to get susceptibility testing done on all blood stream and
clinically relevant isolates!
Use your antibiogram to help chose empiric therapy!
- Echinocandin
- fluconazole
Candidemia Treatment
Narrow to oral therapy:
* Need susceptibilities
* Patients needs to be clinically stable (afebrile, normal tensive / no pressors)
* Negative repeat blood cultures
* Been on appropriate therapy for 48hrs
* Chose the most narrow agent (ideally ___ )
REMOVE THE LINE!
Alternative therapies:
* Amphotericin B formulation 3-5 mg/kg/day (lipid)
* Voriconazole 400 mg BID x 2 doses, then 200 mg BID
Repeat blood cultures q48hrs
Treat for ___ days after first negative blood culture
- fluconazole
- 14 days
Candidemia Treatment (Neutropenic)
- ___ - initial therapy
- Lipid formulation of ___ 3-5mg/kg/day
If not critically ill and no prior azole exposure:
* Fluconazole 800 mg loading dose, then 400 mg daily
* Voriconazole 400 mg BID x 2 doses, then 200-300 mg BID if
additional mold coverage is needed
- echinocandin
- amphotericin B
Candidemia Preferred Treatment
C. albicans: ___
C. glabrata: ___
C. parapsilosis: ___ and ___
C. tropicalis: ___
C. krusei: ___ , ___ and ___
C. lusitaniae: ___ and ___
C. auris: ___
- fluconazole
- Echino
- fluconazole, ampho
- fluconazole
- Vori, echino, ampho
- fluconazole, echino
- echino
Histoplasmosis Clinical Presentation
Disseminated Histoplasmosis
- May be seen in patients exposed to large inoculum or in immunocompromised host (especially if decreased ___ ___ immunity)
- Successful containment of organism with macrophages may not occur
- Progressive illness characterized by persistent yeast-filled macrophages and inability to form granulomas
- In PLWH, disseminated histoplasmosis can occur as a direct result of initial infection or reactivation of a dormant focus
- Symptoms: fever, chills, fatigue, weight loss, night ___ , ___ , cough, chest pain, dyspnea
- CNS histoplasmosis symptoms: fever, headache, ___ , mental status changes
- cell mediated
- sweats, hepatosplenomegaly
- seizure
Histoplasmosis Treatment (Immunocompetent Host)
Acute pulmonary histoplasmosis
- Asymptomatic or mild-moderate disease with symptoms < 4 weeks = NO therapy required
- Mild-moderate disease with symptoms > 4 weeks = ___ 200 mg TID x 3 days, then 200 mg QD or BID for __ - __ weeks
Moderately severe-severe disease
* Lipid ___ 3-5 mg/kg/day x 1-2 weeks, then ___ 200 mg TID x 3 days followed by 200 mg BID for total of ___ weeks
* Amphotericin B deoxycholate 0.7-1 mg/kg/d if low risk of nephrotoxicity
* Methylprednisolone 0.5-1 mg/kg daily for first 1-2 weeks
- Itraconazole, 6-12 weeks
- amphotericin B, Itraconazole, 12 weeks
Histoplasmosis Treatment (Immunocompromised Host)
Disseminated histoplasmosis - Therapy required for all patients!!
- Moderately severe-severe disseminated disease
- Lipid ___ 3-5 mg/kg/day x 1-2 weeks, then ___ 200 mg TID x 3 days followed by 200 mg BID for at least ___ months
Obtain itraconazole concentration after 1-2 weeks (troughs ≥ 1.5 μg/ml
combined itraconazole and hydroxyitraconazole)
Less severe disease
* ___ 200 mg TID x 3 days followed by 200 mg BID x ___ months
* Still monitor trough concentrations
* Alternatives:
* Posaconazole or voriconazole
* Fluconazole less effective (800 mg if used)
- amphotericin B, itraconazole, 12 months
- Itraconazole, 12 months
Coccidioidomycosis Treatment
Primary respiratory infection
* Most patients with symptomatic ___ ___ disease recover without therapy.
Treat patients with large inocula, severe infection, or concurrent risk factors (e.g., ___ infection, organ transplant, ___ , or high doses of corticosteroids)
Considered Severe Infection if:
- Weight loss (> 10%), intense night sweats persisting > 3 weeks
- Infiltrates involving more than one half of one lung or portions of both lungs, prominent or persistent hilar adenopathy
- Complement fixation antibody titers > 1:16
- Inability to work (extreme fatigue), or symptoms that persist > 2 months
- HIV, pregnancy
- primary pulmonary
Coccidioidomycosis Treatment
Primary respiratory infection
* ___ 400-800 mg PO/IV daily
* Itraconazole 200-300 mg PO BID-TID
* Treat __ - __ months
Symptomatic chronic cavitary pneumonia
* ___ 400-800 mg PO/IV daily
* Itraconazole 200-300 mg PO BID-TID
* Treat for ___ months total
Diffuse pneumonia with bilateral or miliary infiltrates
* Amphotericin B (lipid or deoxycholate) for several
weeks, followed by an azole
* Treat for ___ months total
- fluconazole, 3-6 months
- fluconazole, 12 months
- Amphotericin B, 12 months
Cryptococcosis
Causative pathogen: Cryptococcus ___ and Cryptococcus gattii
- Encapsulated yeast found in soil and pigeon droppings
- ___ ___ immunity plays a major role in host defense against infection
- neoformans
- Cell-mediated
Cryptococcosis Clinical Presentation
Pulmonary
* Cough, rales, shortness of breath
Meningitis:
Patients without HIV
* Headache, fever, nausea, vomiting, mental status changes, nuchal rigidity
* Less common – photophobia, blurred vision, papilledema, seizures, hydrocephalus
Patients living with HIV
* Fever, malaise, headache
* Tend to have ___ symptoms due to reduced immune system
- less
Cryptococcosis Diagnosis
___ (most common presentation)
Preform a lumbar puncture and look at CSF
___ inflammatory response in HIV/AIDS with extremely ___ cryptococcal antigen titer
Meningitis
reduced , high
Cryptococcal Meningitis Treatment
Non-HIV Infected, Non Transplant Host
Induction:
- ___ deoxycholate 0.7-1 mg/kg/day or lipid amphotericin B 3-5 mg/kg/day IV plus flucytosine 100 mg/kg/day PO in 4 divided doses for at least 4 weeks
* 4 weeks in patients without neurologic complications and negative CSF cultures after 2 weeks of therapy
* 4 to 6-week induction phase for C. gattii
* Extend induction phase to 6 weeks if neurologic complications or
flucytosine not given
Consolidation:
* ___ 400-800 mg PO daily x __ weeks
* Maintenance:
* ___ 200-400 mg PO daily x __ - __ months
- amphotericin B
- fluconazole, 8 weeks
- fluconazole, 6-12 months
Cryptococcal Meningitis Treatment
HIV-infected patients
Induction:
* ___ 3-5 mg/kg/day IV plus flucytosine 100 mg/kg/day PO in 4 divided doses
* For ≥ __ weeks
Consolidation:
* ___ 800 mg PO daily
* For __ weeks
Maintenance:
* ___ 400 mg PO daily to complete at least __ year of azole therapy
* May be stopped in patients with CD4 count ≥ ___ cells/mm3, who have undetectable viral load on ART for > ___ months, and received at least 1 year of maintenance therapy
___ ART if patient is new HIV diagnosis or not on ART!
- Lipid amphotericin B, 2 weeks
- fluconazole, 8 weeks
- fluconazole, 1 year
- 100, 3
- Withhold
Cryptococcal Meningitis Treatment - (Induction)
HIV-infected patients – Alternative regimens
* Amphotericin B deoxycholate 0.7-1 mg/kg/day IV or Lipid amphotericin B 3-5 mg/kg/day IV for 4-6 weeks
* Amphotericin B deoxycholate 0.7 mg/kg/day IV plus fluconazole 800-1200 mg IV/PO daily for 2 weeks, then fluconazole 800 mg PO daily x 8 weeks
* Fluconazole 800- ___ mg daily plus flucytosine 100 mg/kg/day for 6 weeks
* Fluconazole 1200 mg daily for 10-12 weeks
1200
Aspergillosis Treatment
Invasive pulmonary aspergillosis
___ 6 mg/kg IV q12h for 1 day, then 4 mg/kg IV q12h
* Oral dosage 200-300 mg q12h
* Trough concentrations > 1-1.5 μg/mL associated with clinical response (>5-6 μg/mL associated with toxicity)
Alternative therapy
* Lipid amphotericin B 3-5 mg/kg/day
* Isavuconazole 200 mg q8h x 6 doses, then 200 mg daily
* Voriconazole plus echinocandin in select patients
Primary therapy with an echinocandin is not recommended!
- Primary combination therapy is not routinely recommended (may
be considered for salvage therapy)
Continue treatment for a minimum of __ - __ weeks
- Voriconazole
- 6-12 weeks
Aspergillosis Prophylaxis
___ 300 mg IV q12h on day 1, then 300 mg IV daily
- 300 mg (three 100 mg delayed release tablets) q12h on day 1, then 300 mg daily
- 200 mg suspension PO TID
Alternative agents
* Voriconazole 200 mg PO BID
* Itraconazole 200 mg IV q12h for 2 days, then 200 mg IV
daily or 200 mg PO q12h
* Micafungin 50-100 mg mg IV daily
* Aerosolized amphotericin B
posaconazole
