Fungal Infections

What are the treatment options for tinea corporis? What is the duration of therapy of

each? When should oral therapy be preferred?

Tina Corpis

Ringworm

Usually responds well to topical treatment  QD-BID 1-3weeks Oral- Alternative for pts with extensive involvement and patients who fail topical therapy Terbinafine 250mg QD x 2 weeks

What are the treatment options for tinea cruris? What is the duration of therapy of

each?

Tinea cruris

Groin- Jock itch

Topical QD-BID 1-3 weeks Oral- Alternative for pts with extensive involvement and patients who fail topical therapy Itraconazole 200-400mg QD x 1 week

What are the treatment options for tinea pedis ? What is the duration of therapy of

each?

Tinea Pedis

feet

Topica- 4 weeks Terbinifine cream 1 week Oral- Fluconazole 150mf q week  x 1-4wks

When should patients be referred for T. corporis, T. pedis, T. cruris?

What are the treatment options for tinea capitus and duration for each?

Tinea capitus

fungal infection of the scalp

Systemic treatment is the standard of care for children 1)Oral terbinifine x 4-6 wks  -Granules swallwed with food; DO NOT USE FRUIT BASED FOODS 2) Oral griseofulvin x6-8 wks

Risk factros for Tinea unguium

Age, DM, PAD, Smoking, History of trauma

What is the preferred therapy (and duration) for mild-moderate and moderate-to-

severe Onychomycosis?

Treatment is not mandatory in all pts

Terbinafine counseling pearls

• Take tablets (can crush) without regard to meals; granules with food (non-acidic food, no fruit-based food)

• Contraindicated in chronic or active hepatic disease

• Adverse effects: headache, GI, taste disturbances

• Drug interactions: moderate inhibitor of CYP2D6

Griseofulvin counseling pearls

• Tablet (can crush) and liquid (shake well)

• Take with fatty meal

• Contraindicated in hepatic failure

• Pregnancy category X. Avoid in breastfeeding. Men should avoid fathering a child for at least 6 months after therapy

• Adverse effects: GI, photosensitivity, hepatotoxicity

• Drug interactions: contraceptives, warfarin (decrease effectiveness)

What is the causative organism of Vaginal cutaneous candidiasis (VCC)?

Mostly candida albicans

What are the treatment options for uncomplicated VCC, severe-acute VCC

Uncomplicated (Sporadic, infrequent, non-pregnant, mild-mod)	Fluconazole 150mg oral single dose more preferred for convenience Topical agents
Severe acute (mod-severe)	Fluconazole 150 mg PO Q72 hours for 2-3 doses

Treatment options for recurrent VCC

Defined as > 4 episodes of vulvovaginal candidiasis (VCC) within one year

• Usually caused by azole-susceptible Candida albicans

Treatment:

Induction

1. Fluconazole 150 mg every 72 hours × 3 doses

2. Topical azole daily for 10 to 14 days

Maintenance

1. Fluconazole 150 mg once weekly × 6 months

2. Topical azole twice/week × 6 months

Pregnancy: Use topical azoles for symptom relief

What factors make a patient with VCC complicated?

Recurrent, Pregnant, Immunocompromised, non-albicans

(refer to MD)

What is the treatment of choice including duration for candiduria?

Candiduria

Asymptomatic: Treatment is not indicated UNLESS Low birth weight infants  Neutropenic patients  Patients undergoing urologic manipulation  Symptomatic: Fluconazone 200mg PO.IV QD x 14 d Amphotericin IV or bladder irrigation Flucytosine

How do you treat a non-neutropenic patient with candidemia?

1. Echinocandin: Caspofungin, micafungin, anidulafungin

2. Transition to fluconazole or voriconazole if:

   1. clinicall stable, negative repeat blood cultures following initiation of antifungal

   2. Vori if not susceptible to flucon

Treamt for 2 weeks beyond clearance, consider removing IV catheter

Pref drug in preg with Candidemia

1)Lipid formulation amphotericin

NO AZOLES!

Echinocandins AEs

Nausea, Abnormal liver function, histamine related symptoms

Amphotericin B deoxycolate AEs

Which azoles are notable 3A4 inhibitors

Fluconazole (moderate)
Isavuconazole (moderate)
Itraconazole (strong)
Posaconazole (strong)
Voriconazole (strong)

lol thats all of them

Which azoles are notable 2C19 inhibitors

Fluconzaole
Voriconazole

Which azole is a prodrug

Isavuconzaole

Which azole should be taken with food

Itraconazole tab
Posaconazole tab and suspension (fatty)

Which azoles cause vision changes (3)

Itraconzaole
Posaconazole
Voriconazole

Which azoles cause neuropathy (1)

Voriconazole

Flucystosine

AEs: Leukopenia, Thrombocytopenia, Hepatic, GI