Exam 4 - Fungal (Kays) Flashcards Preview

Therapeutics V Spring 2019 (P3 Spring) > Exam 4 - Fungal (Kays) > Flashcards

Flashcards in Exam 4 - Fungal (Kays) Deck (122):
1

what are the most common fungal pathogens?

Candida species
Aspergillus species
Cryptococcos neoformans
Zygomycetes
Endemic Fungi (related to your region)

2

What are types of Zygomycetes

Rhizopus
Absidia
Mucor

3

what are types of endemic fungi

histoplasma capsulatum
blastomyces species
coccidioides immitis

4

Is it a yeast or a mold?
Candidia

yeast

5

Is it a yeast or a mold?
Aspergillus

mold

6

Is it a yeast or a mold?
cryptococcus

yeast

7

Which fungal pathogen?
is enacpsulated and
primarily affects CNS and respiratory tract

cryptococcus neoformans

8

Which fungal pathogen?
risk factor includes penetrating injuries from natural disasters?

Zygomycetes

9

Which fungal pathogen?
is common in midwestern states/happens from exposure to bat guano/cave exploration/from contrstruction

histoplasma capsulatum

10

Which fungal pathogen?
common in southwestern US

coccidiodies

11

what is the most common species of Candidia?

C. Albicans

12

what is the most drug resistant species of Candidia?

C. Auris

13

Candida species:
increased mortality if empiric antifungal therapy doesn't happen within ______

12 hours

14

Candida species:
what are some risk factors for invasive candidiasis

prolonged ICU stay
central venous catheters
prolonged therapy with broad spec abx
receive parenteral nutrition
recent surgery (esp abdominal)
hemodialysis
diabetes...

15

PD parameter for Amphotericin B?

Peak/ MIC

16

PK of Amphotericin?
CSF?
Renal / Hepatic?
PO or IV?

poor CSF penetration
no adjustment for Renal or hepatic needed
bad PO absorption -- must do IV

17

Dosing Notes about Amphotericin?

do a TEST DOSE
can do bigger doses if use lipid formulations
Infused over 4- 6 hours!!

18

ADEs of Amphotericin?

Infusion related (fever, chills, arhtralgias, myalgias, N/V) & thrombophlebitis

Nephrotoxicity
Hypo kalemia and magnesemia
Bicarb wasting
anemia

19

How to manage Amphotericin infusion related rxns?

pre-treat - APAP, antihistamines, anti-nausea meds
add hydrocortisone to infusion
TOLERANCE WILL DEVELOP

give slower rxn to help with thrombophlebitis

20

MOA of flucytosine

5-FC enters fungal cell --- gets made into 5-FU and gets into fungal RNA and stops protein synthesis

or inhibits thymidylate synthetase and interferes with DNA synthesis

21

Flucytosine is used mainly for what fungal pathogen?

Cryptococcus

22

PK of Flucytosine?
CSF?
Renal/hepatic?
PO or IV?

great CSF
renal adjsut!!/excreted in urine (HD and PD pull it out)
great PO absorption -- oral!

23

drug interactions of amphotericin?

nephrotoxic agents (bc more nephrotoxicity)
Digoxin/Skeletal muscle relaxants -- hypokalemia risk
+ Flucytosine = better therapeutic effect but toxicityyyy

24

ADE of flucytosine?

Bone marrow suppression

25

Normal dose for Flucytosine

100 - 150 mg/kg day
and DIVIDED in 4 doses

26

Monitoring for Flucytosine

CBC/Platelets (because marrow suppression)
SCr/BUN (because renal adjsut)

27

Ketoconazole MOA?

inhibits egosterol synthesis
via inhibiting lanosterol 14 a demethylase
also membrane gets wack without egosterol = leakage

28

Ketoconazole:
-cidal or - static

static

29

PK of Ketoconazole:
CSF?
Renal/Hepatic adjustments?
PO or IV?

negligible CSF
metabolized by liver extensively
PO absorption is related to gastric pH

30

Ketoconazole:
Oral absorption: related to gastric pH how?

inversely!
lower pH (more acidic) = more absorption

31

ADEs of Ketoconazole?

Hepatoxicity
Endocrine: Menstural irregularities, Hair loss, libido/sperm issues, and Gynecomastia

32

Drug interactions of Ketoconazole?

It is a POTENT CYP3A4 inhibitor:
therefore --- anticoag, rifampin, cyclosporine/tacrolimus/sirolimus, phenytoin
ALSO
anything that decreases stomach acid (H2RA, PPIs antacids)

33

PK of Itraconazole:
CSF?
Renal/hepatic?
PO or IV?

poor CSF
liver metab (NO renal adjust)
PO dependent on acidity!! take with cola for capsules (oral solution - acidity doesnt matter)

34

Itraconazole ADEs

Hepatoxicity
CHF -- boxed warning
Avoid (CONTRAINDICATED) in pregnant/nursing women
peripheral neuropathy

35

Boxed warning for itraconazole?

CHF!! (present or history) negative inotropic effect

36

Drug interactions for Itraconazole?

PPIs/H2RAs/Antacids - because acidity needed
CYP3A4 interactions

37

PK of Fluconazole:
CSF?
Renal/Hepatic?
PO or IV?

great CSF
needs renal adjustment
PO absorption is great

38

ADEs of Fluconazole

QT prolongation
Elevation in hepatic transaminase

39

Voriconazole:
Does it cover Aspergillus, Mucor, or both?

Aspergillus - NO MUCOR

40

PK of Voriconazole:
CSF?
Renal/Hepatic?
PO or IV?

IDK about CSF...
renal adjust when IV!!!! (not oral)
great PO availability

41

Oral Voriconazole tips?

acid reducers do NOT matter for this
this is best 1 hour BEFORE OR AFTER a meal

42

ADEs of Voriconazole

Visual disturbances
Elevated LFTs
Phototoxic skin rxns

43

Adjust Voriconazole for renal elimination when?

Adjust when IV and CrCl < 50 mL/min

44

PK of Posaconazole?
CSF?
Renally or Hepatic?
PO or IV

idk about CSF...
Renally adjustment needed

PO -- needs acidic to be absorbed
IV - RENAL ADJUST

45

when do you avoid Posaconazole and Voriconazole due to renal issues

when IV formulation and CrCl is < 50 mL/min

46

Drug interactions for Posaconazole?

CYP 4 dayz
and acid reducers!

47

ADes of Posaconazole

Elevated LFTs/billirubin
hypokalemia
Rash

48

PK of Isavuconazole
PO or IV?
Renal/hepatic?

PO has great bioavail - so PO or IV is fine
NO renal adjustment needed
NO hepatic adjustment needed

49

Why do some IV azoles need to be avoided when CrCl is < 50 mL/min

something to do with their formulation having cyclodextrin??
(Isavuconazole does not have cyclodextrin = does not need renal adjustment)

50

ADEs of Isavuconazole

increased LFTs
infusion related reaction
***NO QT PROLONGATION** actually SHORTENS QT

51

what is an abnormal Qt interval?

male over 450 ms
females over 470 ms

52

Contraindications for Isavuconazole?

coadministration of any strong CYP3A4 inhibitors or inducers

patients with familial SHORT qt syndrome (this drug will shorten QT)

53

Examples of strong CYP3A4 inhibitors:

Ketoconazole
high dose ritonavir

54

Examples of strong CYP3A4 inducers

CBZ
rifampin
St. Johns Wort
Long acting barbiturates

55

MOA of Caspofungin

glucan synthesis inhibitor = prevents from fungal cell wall from being made

56

The echinocandin drugs have what suffix?

-fungin

57

spectrum of echinocandin?

Candida and aspergillus

58

Azole antifungals affect cell ______
Echinocandins affect cell ______

Azole: affect cell membrane
Echinocandins: cell wall

59

which echinocandin needs to be dose reduced with hepatic dysfunction

caspofungin

60

Echinocandins:
PO or IV?

IV!!
very poor bioavailability

61

VVC stands for?

vulvovaginal candidiasis

62

Complicated or uncomplicated VVC?
sporadic infection that is susceptible to all forms of antifungal therapy regardless of treatment duration

uncomplicated

63

Complicated or uncomplicated VVC?
Recurrent VVC

complicated

64

Complicated or uncomplicated VVC?
Severe disease

complicated

65

Complicated or uncomplicated VVC?
Non-candida albicans infection

complicated

66

Complicated or uncomplicated VVC?
Candida albicans infection

uncomplicated

67

Complicated or uncomplicated VVC?
diabetes/immunocomproised/pregnancy

complicated

68

VVC:
Candida species - mono, di, or tri morphic

di

69

patient education for VVC?
Avoid ________ to prevent worsening irritation
Keep genital area _________
______ to soothe the skin
________ not recommended

avoid harsh soaps
keep it clean and dry
cool baths to soothe
do not douche

70

Pharm Treatment of VVC:
Topical preparations can decrease efficacy of what?

latex condoms and diaphragms

71

Pharm Treatment of VVC:
Oral or Topical treatment is better?

Equally therapeutic

72

Pharm Treatment of VVC:
Treat for how long if uncomplicated?

can be 1 day.. (1 dose fluconazole)
or like 3 - 7 for various topical treatments

73

Pharm Treatment of VVC:
Treat how long if complicated?

10 - 14 days!
(do this if uncontrolled diabetes or immunocompromised)

74

what does OPC stand for and what is it

oropharyngeal candidiasis aka THRUSH
candida infection of the oral mucosa

75

what does EC stand for and what is it

esophageal candidiasis
esophagus infection from candida

76

what is the primary line of defense against OPC and EC

cell mediated immunity (CD4 T cells)

77

LOCAL risk factors for OPC and EC?

steroids/abx
dentures
xerostomia due to drugs, chemo, radiotherapy to head/neck, and BMT(?)
smoking
any disruption to oral mucosa

78

patients with ______ have had much less incidence of OPC and EC due to great drug development

HIV
(HAART is savin' them)

79

SYSTEMIC risk factors for OPC and EC?

Drugs (cytotoxic, steroids, immunosuppressants after organ transplant)
Neonates or elderly
HIV infection/AIDS
diabetes
malignancy
nutritional deficiencies

80

OPC or EC:
which one is more severe

EC

81

OPC or EC:
which one may have a fever more than the other

EC

82

OPC Treatment:
Treat for how long?

7 - 14 days

83

OPC Treatment:
If mild infection -- treat how?

TOPICALLY
with clotrimazole troches or nystatin susp
or miconazole buccal tab

84

OPC Treatment:
If pt is refractory, cannot tolerate topical agents, have moderate - severe disease, or high risk for disseminated systemic disease (aka neutropenic) --- treat how?

do SYSTEMIC
Fluconazole!!
Itraconazole
or Posaconazole

85

OPC Treatment:
If fluconazole refractory -- treat how?

treat for 14 DAYS
kinda try any antifungal but itraconazole is good

(even try amphotericin...)

86

EC Treatment:
Treat for how long?

14 - 21 days?

87

EC Treatment:
Topical treatment when?
Systemic treatment when?

NEVER topical for EC
do SYSTEMIC!!

88

EC Treatment:
Treatment options?

Fluconazole...
itraconazole...
kinda whatever just do SYSTEMIC

89

EC Treatment:
If fluconazole refreactory -- treat how?

treat for 21 - 28 days
itraconazole and like every other antifungal option...

90

Risk factors for fungal skin, hair, and nail infections?

prolonged exposure to sweaty clothes
failure to bathe regularly
lots of skinfolds
sedentary/confined to bed

91

how to treat tinea capitis

oral therapy --- terbinafine daily 4 - 8 weeks (clean combs/brushes)

92

How to treat tinea unguium

aka onychomycosis
ORAL therapy
terbinafine: 6 - 12 wks
or
itraconazole 8 - 12 wks
or
fluconazole: 6 - 12 mos
(toes need treated longer)

93

what are the different types of histoplasmosis

acute pulmonary
chronic pulmonary
disseminated
HIV infected pts

94

Acute Pulmonary Histoplasmosis treatment:
mIld-mod disease with sxs > 4 wks

itraconazole 6 - 12 weeks

95

Acute Pulmonary Histoplasmosis treatment:
if mod - severe disease?

amphotericin x 1 - 2 weeks THEN itraconazole
also medrol for first 1 - 2 weeks

96

Disseminated Histoplasmosis treatment:
if mod-severe disease?

amphotericin x 1 - 2 weeks then itraconazole for 12 months

97

Disseminated Histoplasmosis treatment:
if less severe disease?

itraconazole x 12 months

98

if C. glabrata strain --- what drug(s) are preferred?

echinocandin

99

if C. parapsilosis strain --- what drug(s) are preferred?

fluconazole or lipid amphotericin

100

if C. krusei strain --- what drug(s) are preferred?

enchinocandin, lipid amphotericin, or vori

101

what antifungals cover mucor?

amphotericin
posaconazole
isavuconazole

102

what antifungal is the DOC for histoplasma

itraconazole

103

what antifungal is DOC for aspergillus

voriconazole

104

what fungi do echinocandins cover

candida and aspergillus

105

what fungi does 5-FC cover?

candida and cryptococcus

106

what fungi does ketoconazole cover?

candida ALBICANS and cryptococcus and histo

107

what two antifungal drugs cover everything but mucor
"everything" = candida, aspergillus, cryptococcus, histo, blasto, cocci

itraconazole and voriconazole

108

what does isavuconazole cover?

aspergillus
mucor
rhizopus

109

if we find candida in respiratory tract --- what do we do?

nothing probably --- its usually colonization/ candida does not cause pneumonia

110

if we find candida in the urine what do we do?

if asymptomatic and NOT high risk for dissemination --- let it goooo

111

who are high risk pts for dissemination form candida UTI?

low birth weight infants
pts undergoing urologic procedure
neutropenic patients

112

which fungus is uncommon in HIV infected patients

aspergillus

113

galactomannan is a cell wall polysaccharide that is specific to the _________ fungus species and is detectable in serum/other body fluids

aspergillus

114

________ is the most important predisposing factor to the development of invasive aspergillosis

prolonged neutropenia
(NOT HIV infection!)

115

DOC for invasive pulmonary aspergillosis

voriconazole

116

main drug to use for prophylaxis of aspergillosis

posaconazole

117

who would get aspergillosis prophylaxis

pts with neutropenia risk (cancer patients and bone marrow transplant pts)

118

which antifungal has a saturable metabolism/pk is NOT linear

voriconzaole

119

which antifungal agents need renal adjustment

flucytosine and fluconazole
(voriconazole IV and posaconazole IV need to be avoided due to cyclodextrin build up in renal dysfunction)

120

which antifungal agents need an acidic gastric environment to get absorbed

ketoconazole
itraconazole CAPSULE
posaconazole

121

what agents have cyclodextrin in them

IV voriconazole
and
IV posaconazole

122

what drugs used for cyptococcus infection?

amphotericin AND 5-FC