Medical Minute Recap: Antifungals

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September 1, 2015 by dailybolusoflr

By: Shaughn Keating, MD

True Pathogenic Fungi- Usually need high index of suspicion and travel to endemic area +/- BAL vs biopsy. Look for cavitary lesions or mediastinal adenopathy.
  • Histoplasmosis- pulmonary disease or disseminated
    • Mild pulmonary – itraconazole
    • Severe or Disseminated disease- Amphotericin B +/- steroids
  • Blastomycosis- mostly pulmonary, occasionally meninges, skin, bones, GU
    • Mild pulmonary – itraconazole
    • Severe or Disseminated disease- Amphotericin B
  • Coccidioiodomycosis- mostly pulmonary, meningitis/vasculitis of cerebral vessels
    • Healthy patient/mild illness- Monitoring
    • Immunosuppressed or Severe- Fluconazole or Itraconazole
Opportunistic Fungi- Severe localized infections or disseminated
  • Candida species- Most common systemic fungal infections in ICU settings.  Candidemia has 20-40% attributable mortality for ICU patients.

See table 1-4 for Risk Factors for ICU Patients
https://www.accp.com/docs/bookstore/psap/p7b02sample02.pdf


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  • Rising Candidal azole resistance, and now cases of echinocandin resistance
  • Empiric Candida Treatment: Delay to therapy increases mortality
    • IDSA recommends empiric therapy if risk factors and no other known cause of fevers. (B-III)
    • If non-neutropenic AND clinically stable AND no recent azole AND in a medical center where C. glabrata & krusei are uncommon fluconazole
    • Otherwise echinocandin drug of choice for candidemia:
      • Caspofungin loading 70 mg IV
      • Anidulafungin loading 200 mg IV
      • Micafungin 100 mg IV (no loading dose needed)
    • Remove central intravenous catheters if possible
    • CNS candidiasis, endophthalmitis, endocarditis may require Amphotericin B
  • Molds: Zygomycetes, Aspergillus with mortalities up to 100% if untreated
    • Can cause rhino-orbital-cerebral and pulmonary infections, especially in diabetics
    • Mucorales intrinsically resistant to voriconazole
    • Empiric treatment Amphotericin B

References:
  1. Ashley, E. Fungal Infections in the Intensive Care Unit.  PSAP-VII Critical and Urgent Care. ACCP, 2010.
  2. Chapman SW, Dismukes WE, Proia LA, et al. Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis 2008; 46:1801.
  3. Freifeld AG, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 Update by the Infectious Diseases Society of America.Clin Infect Dis. 2011 Feb 15;52(4):427-31.
  4. Pappas, P, et al. Clinical Practice Guidelines for the Management Candidiasis: 2009 Update by the Infectious Diseases Society of America Clin Infect Dis. (2009) 48 (5): 503-53.
  5. Wheat LJ, Freifeld AG, Kleiman MB, et al. Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. Clin Infect Dis 2007; 45:807.

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