id exam 4 treatment

Vulvovaginal Candidiasis uncomplicated and duration

• Topical azoles for 1-7 days or

• Fluconazole 150 mg PO x 1

duration not critical

Vulvovaginal Candidiasis complicated and duration

•Topical azoles for 7-14 days or

• Fluconazole 150 mg PO Q72H x 2-3 doses

extended duratation

Vulvovaginal Candidiasis pregnant and duration/ what avoid

Topical azoles for 7 days preferred

AVOID Systemic azoles—> fetal malformations

Vulvovaginal Candidiasis recurrent and duration

Treated in 2 stages:

‒ Initial regimen: Topical azoles x 7-14 days OR fluconazole 100-200 mg PO

Q72H x 3 doses

‒ Maintenance regimen: Fluconazole 150 mg PO weekly x 6 months

Vulvovaginal Candidiasis antifungal-resistant

—Ibrexafungerp 300 mg PO Q12H x 2 doses

‒ Boric acid 600 mg intravaginal capsule daily x 14 days

‒ Nystatin intravaginal suppositories 100,000 units daily x 14 days

‒ Flucytosine 17% cream intravaginally (± amphotericin B 3% cream) daily x 14 days

Oropharyngeal Candidiasis mild and duration

Topical agents x 7-14 days

First line:

• Clotrimazole 10 mg troche 5 times daily

• Miconazole 50 mg mucoadhesive buccal tablet daily

Alternate topical agent

• Nystatin 100,000 units/mL 4-6 mL swish and swallow 4 times daily

• Nystatin pastilles (200,000 units) 1-2 pastilles 4 times daily

Oropharyngeal Candidiasis mod/severe and duration

Systemic agents x 7-14 days

• First-line systemic agents

‒ Fluconazole 100-200 mg PO daily

Oropharyngeal Candidiasis + HIV and duration

Systemic agents x 7-14 days

‒ Fluconazole 100 mg PO daily

topical is alternative therapy

Oropharyngeal Candidiasis + fluconazole refractory and duration

Systemic agents for up to 28 days

• First-line systemic agents

‒ Itraconazole solution 200 mg PO daily

‒ Posaconazole suspension 400 mg PO BID x 3 days, then 400 mg PO daily

Esophageal Candidiasis treat and duration

systemic agents 14-21 days

first line:

• Fluconazole 200-400 mg PO daily

• IV fluconazole or an IV echinocandin

fluconazole-refractory disease

• Itraconazole oral solution, voriconazole IV or PO, posaconazole suspension or delayed release tablets, IV echinocandin, or amphotericin B deoxycholate

Which Dermatophyte infections prefer topical? wb systemic?

topical: Tinea pedis, Tinea cruris, Tinea corporis

systemic: Tinea capitis, Onychomycosis

Empiric treatment of candidemia

First-line therapy: echinocandin agent

alternate: fluconazole or lipid formulations of amphotericin B

Targeted therapy for candidemia. When Fluconazole and when Echinocandin

Fluconazole: C. albicans, C. tropicalis, C. parapsilosis

Echinocandin: C. glabrata, C. krusei, C. auris

• first 2 u can use voriconazole too

Invasive Aspergillosis treatment

Drug of choice: Voriconazole

alternatives: Liposomal amphotericin B, Isavuconazole, Posaconazole, Other lipid formulations of amphotericin B

Invasive Aspergillosis Combination therapy

Voriconazole PLUS an echinocandin

in severe, it helps mortality for probable aspergillosis

routine NOT reccomended

Fusariosis

Drug of choice

o Voriconazole

Alternative therapies

o Amphotericin B formulations

o Posaconazole (salvage therapy)

Mucormycosis treatment

• source control

drug of choice

• lipid formulation of Amp B

• use 5-10mg intially (higher dose); if brain involved use 10mg

Mucormycosis combo treatment

Polyene PLUS echinocandin or azole

Mucormycosis step down to PO treatment and duration

Isavuconazole or posaconazole

treat until signs are gone

Histoplasmosis Mild to moderate

no treatment unless persistent >1 month symptoms then Itraconazole PO x 6-12 weeks

Histoplasmosis Moderately severe to severe diffuse

Lipid formulation of amphotericin B x 1-2 weeks, followed by itraconazole x 12 weeks

if hypoxiema—> Methylprednisolone

Histoplasmosis Chronic cavitary pulm

Itraconazole PO x 12-24 months

Histoplasmosis Progressive disseminated infection mild-mod

Itraconazole PO x ≥ 12 months

Histoplasmosis Progressive disseminated infection mod-severe

Lipid formulation of amphotericin B x 1-2 weeks, followed by itraconazole x ≥ 12 months

Coccidioidomycosis Primary infection

uncomplicated pneumonia; Valley Fever

mild/nondebilitating: supportive care

Debilitating symptoms, extensive pulmonary disease, or frail/high risk:

Fluconazole PO or itraconazole PO x 3-6 months or longer

Coccidioidomycosis Chronic coccidioidal pneumonia

Fluconazole PO or itraconazole PO x 12 months or longer

Coccidioidomycosis Meningitis

Fluconazole or itraconazole treatment for life (extremely high relapse rates)

• Amphotericin B formulations reserved for refractory cases

Blastomycosis overall treatment

mild-mod—> Itraconazole PO x 6-12 months

mod/severe- severe: Amphotericin B formulation x 1-2 weeks, followed by itraconazole PO x 6-12 months

Central nervous system disease: Amphotericin B formulation x 4-6 weeks, followed by PO azole (fluconazole, itraconazole, or voriconazole) for ≥ 12 months and until resolution of CSF abnormalities

Initial regimens for HIV (recommended)

1) Dolutegravir (Tivicay®) + lamivudine or emtricitabine/tenofovir (TDF or TAF)

2) Biktarvy- Bictegravir/emtricitabine/TAF

3) Dovato- Dolutegravir/lamivudine

HIV + HepB what drugs do u need? also give BBW

Tenofovir (TDF or TAF) + FTC or lamivudine NEEDED

BBW: Caution against acute exacerbation of viral hepatitis if d/c’d abruptly

NRTIs, elimination

Lamivudine and emtricitabine

renally elim; except abacavir

when should u avoid TAF

if liver failure and <30 GFR

INSTIs, DDI, dosing

Dolutegravir(1x daily) and bictegravir(1x daily, only in coformulation of biktarvy)

DDI w polyvalent cations (don’t need to space w/ Ca 2+ or Fe3+ if with food)

Protease Inhibitors NEED what, DDI

Darunavir

highest genetic barrier—> NEED PK booster, + need food

Abacavir elim, rxns and ADEs

hepatic

hypersensitivity IgE-mediated

higher risk of CV events

NEED TO TEST FOR POLYMORPHISM HLA-B*5701

Rilpivirine vs Doravirine important, DDI

Rilpivirine:

NEED to take w food >400 calories

avoid with PPI

Doravirine:

good option for ppl w food problems or acid issues

Same day/ Rapid start ART HIV

Biktarvy

Dolutegravir (Tivicay®) + lamivudine or emtricitabine/TDF or TAF

Darunavir/cobicistat/emtricitabine/TAF (Symtuza®)

Failing HIV new regimen necessities

2 fully active agents if atlease 1 hsa a high genetic barrier

Lenacapavir loading dose, maintence dose and PrEP formulation

LD: 2 tabs day 1 + 2 SubQ inj, 2 tabs day 2

MD: Q6M by IV

PrEP: every 6 months IM

long acting prevention injectable

HIV PEP(post exposure prophylaxis) when start, and duration

START ASAP(within hours); less effective in >72 hrs

give 28 day course

HIV PEP occupational exposure drugs

1) FTC/TDF (Truvada®) or FTC/TAF (Descoy®) + raltegravir BID

2) FTC/TDF (Truvada®) or FTC/TAF (Descoy®) + dolutegravir (Tivicay®) daily

3) Biktarvy®) daily

+ follow up

HIV PrEP agents

1) Emtricitabine/TDF (Truvada®) tab

2) Emtricitabine/TAF (Descovy®) tab

3) Cabotegravir (Apretude®) inj.

• Every 2 months

4) Lenacapavir (Yeztugo®) inj.

• Every 6 months

Antiretroviral Regimens for Antepartum Care

Emtricitabine or lamivudine + TDF or TAF + Dolutegravir or Bictegravir

alternate: Dovato

Infusion-Related Reactions for Amp B

remember NOT liposomal form

Premedication 30-60 minutes prior to dose

NSAID ± diphenhydramine, acetaminophen ± diphenhydramine, hydrocortisone

Prevention of nephrotox in Amp B

1. Saline loading (specifically SALT)

2. Preferential use of lipid formulations

drug of choice for aspergillus and fusariosis

voriconazole

Which azole is the drug of choice in high risk oncology patients?

posaconazole

Mucormycosis drug

Isavuconazole

Who do enchinocandins cover first line of?

candida

empiric coverage of Candidiasis (enchinocandins)

Caspofungin, micafungin, and anidulafungin

Rezafungin may be reserved for patients with limited alternative options

which drugs are bacteriacidal for TD

Isoniazid, Rifampin, FQs

which drugs are sterilizing activity for TB?

rifampin and pyrazinamide

intensive phase TB treatment and duration

rifampin ,isonaizd, ethambutol and pyrazinamide

2 months

LTBI Treatments and duration

3HP—> 3 month isonizaid and rifapentine

4R—> 4 months rifampin

1HP—> 1 month isoniazid and rifapentine

continuation phase TB treatment and duration

Ionzaide + rifampin for 4 months