ID 3 - fungals

Yeasts (2)

• Candida species

• Cryptococcus

Molds (2)

• Aspergillus

• Zygomycetes (mucor)

Dimorphic fungi (2)

Histo and blasto

Amp B MOA

Binds erogosterol causing cell death

Which amp B form has the most toxicities?

A. Amp B Deoxycholate

B. Amp B Lipid Complex

C. Liposomal Amp B

A. Amp B Deoxycholate

which is the conventional form

Amp B BW (2)

• Med errors that have resulted in cardiopulm arrest and death

• Conventional amp B should not exceed 1.5 mg/kg/day

Amp B adverse effects (6)

• Infusion related - chills, HA, malaise, rigors

• BP changes

• HypoK

• HypoMg

• Nephrotoxicity

Amp B deoxycholate (conventional) pre-medication (4)

• APAP/NSAID - fever

• Diphenhydramine and/or hydrocortisone

Flucytosine MOA

Penetrates fungal cells and is converted to fluorouracil which interferes with fungal RNA and protein synthesis

Flucytosine can cause dose related _______.

Myelosupression

Azoles MOA

Decrease ergosterol synthesis and cell membrane formation

What azole can cause heart failure?

Itraconazole

Itraconazole BW (3)

• Can worsen or cause HF

• Many DDI that increase those drug conc

• Can increase QTc

Ketoconazole BW (3)

• Hepatotoxicity

• QT prolong

• Only use when benefit>risk

What is the main AE with azoles? (2)

• Hepatotoxicity

• QTc/DDI

Voriconazole main AE (3)

• visual changes

• hallucinations

• photosensitivity

What is the only azole that is renally cleared?

Fluconazole - needs dose adj when CrCl ≤50

What 2 azoles can penetrate the CNS and be used to treat fungal meningitits?

Fluconazole

Voriconazole

What azole can cause familial QT shortening?

Isavuconazole

What azole can cause drug particulates when given IV so have to use a FILTER? (2)

Isavuconazole & posaconazole

What azole requires an acidic environment for absorption?

Ketoconazole and Itraconazole

If on PPIs or H2Ras need acidic drink (coke)

Azoles PK **

• ALL are CY3A4 inhibitors

• Fluc and vori can also inhibit CYP2C9 - so watch for warfarin INR

What drugs have SBECD vehicle and therefore can accumulate in renal dysfunction? (2)

• Voriconazole (IV)

• Posaconazole

Itraconazole tabs/caps vs. solution in regards to taking with food

• Tabs/caps take with food

• Solution take on empty stomach

T/F: Take posaconazle on an empty stomach

FALSE - take both tablets and suspension with food

Echinocandins MOA

Inhibit synthesis of Beta (1,3)-D glucan (part of the fungal cell wall)

Echinocandins are effect against most _____ species

Candida

What symptoms can echinocandins cause?

histamine mediated - rash, itching, swelling

What is the only echinocandin that is NOT given once daily?

Rezafungin

Echinocandin medication examples (2)

• Micafungin (mycamine)

• Caspofungin (Cancidas)

Do echinocandins require renal dose adjustments?

NO

Main adverse effect with terbinafine?

Increased LFT's/hepatotoxicity

Oral thrush bug

Candida albicans

Oral thrush TX **

• Topical clotrimazole or miconazole

• HIV pts: fluconazole

• Alternative: nystatin

How do you use nystatin for oral thrush?

Swish the suspension in mouth for several minutes and swallowed

T/F: Shake nystatin well before using

True

Esophageal infection with C. albicans TX **

• Fluconazole

• Alt: Echinocandin

Candida kruseia and glabrata bloodstream infection TX**

• Echinocandin

• Alt: Amp B

Aspergillus TX **

• Voriconazole

• Alt: Isavuconazole, amp B

Cryptococcus meningitis TX **

• Amp B + 5-FC

• Alt: high dose fluconazole

Nail bed infection TX **

• Terbinafine or itraconazole

Alt: Fluconazole

what yeast does ampho B cover

Cryptococcus neoforms

Which molds dose ampho B cover

Aspergillus

What is ampho B compatible with

D5W only

Does conventional or lipid based ampho B need filtered

Lipid based ampho B

What is fluctyosine converted to

fluouracil

Flucytosine + ampho B is used to treat what

Invasive crytococcal meningitis

Disease treated by fluconazole (Diflucan) PO 150 mg x 1

vaginal candidiasis

what is voriconazole the tx of choice for

Aspergillus

Which azole does not cause QTC prolongation

isavuconazole (cause QT shortening)

2 azoles that penetrate CNS and can treat fungal meningitis

Fluconazole

Voriconazole

Which echinocandin needs to be protected from light

Micafungin

Admin of all echinocandin

IV

Griseofulvin indication

Fungal infections of skin, hair, nails

Griseofulvin contraindications

pregnancy

Griseofulvin side effects

photosensitivity

Increase LFTs

Griseofulvin take with or without food

With fatty meal and or milk

Tx for oropharyngeal candidiasis

Clotrimazole troche/lozenge

Terbinafine topical OTC cream

Lamisil AT

Candida albicans oropharyngeal infection (thrush) tx

Mild disease: topic antifungals (clotrimazole, miconazole)

Moderate disease or HIV: fluconazole