Patho+Pharm Exam 1 Drugs

• More common 

• Affect nails and mucous membranes 

  • Moist areas (ex. Feet enclosed in shoes) 

• Treated with topical agents 

• Deeper infections (scalp and nails) may require oral systemic antifungal therapy

Superficial

• Affect internal organs (typically lungs, brain, digestive organs) 

  • Need very specific antifungal treatments 

• Are less common 

• Can be fatal in immunosuppressed patients, who’re more at risk

• Treated with oral or parenteral agents

Systemic

• fungal infection systemic

• Opportunistic: happens in immunocompromised ppl

• People usually asymptomatic

• Aspergillosis 

• Opportunistic 

• Most commonly affects the lungs but can spread to other organs

Aspergillus fumigatus and other species

• fungal infection systemic

• Blastomycosis 

• Begins in the lungs and spreads to other organs 

  • Caused by breathing in spores (lungs)

  • Can be asymptomatic but also lead to RBS (respiratory distress syndrome)

Blastomyces dermatitidis

• fungal infection systemic

• Candidiasis 

Most common opportunistic fungal infection (ex. Yeast infection), and may affect nearly any organ

Candida albicans and other species

• fungal infection systemic

• Coccidioidomycosis 

• Begins in the lungs and spreads to other organs

  • Dangerous and possibly life threatening 

• Also found in soil but can be breathed in by spores

• Rare but can be dangerous/life threatening 

Coccidioides immitis (aka Valley fever)

• fungal infection systemic

• Cryptococcosis 

• Opportunistic (immunocompromised pts) 

• Begins in the lungs, but is the most common cause of meningitis in patients with AIDS 

  • Caused by breathing in spores

Cryptococcus neoformans

• fungal infection systemic

• Histoplasmosis 

• Begins in the lungs and spreads to other organs 

• Also found in soil, bird droppings, bat droppings

  • In health hx, we must remember to ask how they got this?

Histoplasma capsulatum

• fungal infection systemic

• Pneumocystis pneumonia 

• Opportunistic 

  • Immunocompromised hosts 

• primarily causes pneumonia of the lung but can spread to other organs

Pneumocystis jiroveci

• fungal infections superficial

• Candidiasis 

• Affects the skin, nails, oral cavity (thrush), vagina

Candida albicans and other species

• fungal infections superficial

• Athlete's foot (tinea pedis), jock itch (tinea cruris), and other skin disorders

Epidermophyton floccosum

• fungal infections superficial

• Ringworm of the scalp (tinea capitis) 

  • These organisms feed on the keratin in our skin

Microsporum species

• fungal infections superficial

• Sporotrichosis: primarily affects the skin and superficial lymph nodes 

  • Aka Rose gardener’s disease

  • Thorns on roses can cause microcuts 

  • Spores found in soil which can come into contact with cut

Sporothrix schenckii

• fungal infections superficial

• Affects the scalp, skin, and nails 

• Causes skin rash

Trichophyton species

A fungal infection of the scalp

tinea capitis

A fungal infection of the unguium/onychomycosis

nails

A fungal infection of the corporis

trunk

A fungal infection of the manus

ring shaped patch; usually on hands

A fungal infection of the pedis

feet

A fungal infection of the cruris

usually groin area

A fungal infection of the thrush

white layer around mouth, tongue, cheeks

• Toenail fungal infections

• PO medication (by mouth); systemic treatment for superficial fungal infection 

• MOA: Fungicidal activity 

  • Inhibits action of enzymes squalene epoxidase 

  • Causes cell death by destroying the enzyme (which will destroy cell wall) 

• Classification: Antifungal-allylamine 

• Primary use: onychomycosis 

• Adverse effects: headache, dermatitis, Gi distress, taste disturbances, and liver enzyme abnormalities (rare) 

• Nursing considerations: 

  • Treatment is for many weeks 

  • Baseline LFTs (liver function test), monitoring 

  • Inhibitor of CYP2D6

    • This enzyme helps with liver metabolism; its inhibition causes difficulty in drug metabolism of all drugs (including any meds the pt is taking)

    • Leads to higher drug concentration

Commonly used: terbinafine (Lamisil) PO

• Topical Infections

• MOA: increases keratin resistance to fungal invasion 

  • After absorption, medication is deposited in keratin precursor cells

  • Prevents fungal invasions in areas of high keratin; infected keratin sheds and is replaced by fungus free tissue

  • Affects mitosis of fungi, preventing fungi from growing 

• Classification: Antifungal-allylamine 

• Primary use: tinea capitis; onychomycosis 

• Adverse effects: headache, nausea, vomiting, diarrhea, photosensitivity (sensitivity to light) 

• Nursing considerations: 

  • Advise patients to abstain from ETOH (alcohol)

  • Contraindicated with liver failure 

    • Pts with liver failure should not be given this!! 

    • Many drug to drug interactions

  • Administer with fatty meal for improved absorption

  • Not for use in pregnancy or lactation 

    • Category X; most dangerous for pregnant women 

  • Many drug-drug interactions

Commonly used: griseofulvin PO

• superficial infections

• Polyinhibitor 

• MOA: binds to sterols in the fungal cell membrane, allowing leakage of intracellular contents 

  • Destroys cell membranes

• Classification: Antifungal-polyene 

• Primary use: Candida infections of intestines, vagina, skin, mouth 

• Adverse effects: minor skin irritation, nausea, vomiting, diarrhea 

• Nursing considerations: 

  •  For oral candidiasis (thrush), apply with a swab to the affected area in infants and children because swishing is difficult or impossible.

    • Have to swab it for them 

  • For adults with oral candidiasis (thrush), the drug should be swished in the mouth for at least 2 minutes.

    • Similar to mouth wash 

Commonly used: nystatin (Mycostatin) top, PO

• systemic infections

• Very strong, very serious, lifesaving medication 

• Drug of choice for systemic mycoses

• Also polyinhibitor 

• Very little is known on its excretion; can stay in body system for very long time

• MOA: binds to ergosterol in fungal cell membranes; causes them to become permeable or leaky 

  • Disrupts outer cell membrane; becomes antifungal 

• Classification: Antifungal-systemic polyene 

• Effective against: Candida sp, Cryptococcus, Aspergillus sp.-**Used in life threatening infections** 

  • Effective against most fungal infections but only should be used for life threatening infections

• Adverse effects: fever, chills, vomiting, headache; serious: hypotension (low BP), dysrhythmias; nephrotoxicity (damage to kidneys); phlebitis (inflammation of vein) 

• Nursing considerations: 

  • Not for use in renal failure; strict monitoring of electrolytes 

    • b/c nephrotoxic 

  • Monitor IV site of infusion diligently-phlebitis common 

    • Can cause inflammation of the vein 

  • Infuse slowly because cardiovascular collapse may result if the medication is infused too rapidly.

  • Administer premedication, such as acetaminophen, antihistamines, and corticosteroids, to decrease the risk of hypersensitivity 

reactions

Commonly used: amphotericin B (Fungizone) IV

• systemic infections

• Yeast infections, etc

• Usually one time dose

• Topical = athletes foot, etc

• MOA: to act by interfering with synthesis of ergosterol; inhibit 14 alpha-demethylase 

  • Affects cell membrane 

  • Broad spectrum so affects many fungal species but much lower toxicity 

• Classification: Antifungal Azole 

• Primary use: to treat fungal infections in CNS, bone, eyes, urinary tract, respiratory tract 

• Adverse effects: nausea, vomiting, diarrhea reported at high doses, some hepatotoxicity

  •  toxicity to the liver b/c it inhibits of CYP enzyme → raising levels of other drugs 

• Nursing considerations: 

  • Used cautiously in patients with CKD (chronic kidney disease)

    • b/c of excretion 

  • Monitor blood sugar with concurrent use with oral hypoglycemic

    • Can decrease blood sugar levels  

  • Many drug-drug interactions

    • Other drug levels can be raised again b/c of CYP enzyme inhibition 

  • Usually not given in hospital but to pt at home

    • Make sure to educate pt and ask about any other meds they are taking 

Commonly used: fluconazole (Diflucan); itraconazole (Sporanox), ketoconazole (Nizoral) (PO/topical), clotrimazole (topical, vaginal)

• antiprotozoal medications

• ex) malaria, trichomoniasis, etc. 

• Safe to take outpatient

• Antibiotic properties; effective against some bacteria

  • MOA: disrupts nucleic acid synthesis; has antiprotozoal and antibiotic activity 

  • Classification: Anti-infective, anti-protozoan 

  • Primary use: trichomoniasis, respiratory, bone, skin infections; H. pylori PUD and PMC and Crohn’s disease 

  • Adverse effects: anorexia, nausea, diarrhea, dizziness, headache, dry mouth, unpleasant metallic taste; dark urine 

  • Nursing considerations: 

    • Contraindicated in first trimester of pregnancy 

    • Advise patients to not drink alcohol ETOH (ETOH = ethanol) while taking this medication

    • Caution with immunosuppressed patient

• Commonly used: metronidazole (Flagyl), PO, IV