Exam #4: Invasive Fungal Infections (Metzger)

Question 1

Describe the fungal outbreak in 2012

Answer 1

• a compounding pharmacy produced “products” contaminated with fungus that was used to inject in patients w/ inflammatory joint issue.
• 64 patients died

Question 2

Characteristics of Fungi? (3)

Answer 2

• eukaryotes w/ defined nucleus
• rigid CELL WALL (made up of chitin)
• cytoplasmic membrane

Question 3

T/F Fungal susceptible are MORE reliable than bacterial susceptibilities

Answer 3

FALSE:

fungi grow a lot more slower than bacteria

Question 4

What plays an important role in the clinical outcome of patients with fungal infections?

Answer 4

host factors

if a pts WBC are suppressed, then its hard to get rid of the infection even if you have the right agent

Question 5

_______ therapy is key for fungal infections

Answer 5

empiric

based on risk factors, signs and symptoms, etc

Question 6

T/F There are NO reliable breakpoints for amphtericin B

Answer 6

TRUE

Question 7

Fluconazole

Answer 7

Diflucan

Question 8

Itraconazole

Answer 8

Sporanox

Question 9

Voriconazole

Answer 9

Vfend

Question 10

Posaconazole

Answer 10

Noxafil

Question 11

Isavuconazole

Answer 11

Cresemba

Question 12

_____ is used most commonly for CANDIDA INFECTIONS in the hospital; ONLY given intravenously

Answer 12

echinocandins

• Caspofungin
• Micafungin
• Anidulafungin

Question 13

What are 2 things that we worry about with Amphotericin?

Answer 13

• infusion related reactions

- toxicities

Question 14

The ______ formulations of Amphotericin commonly cause INFUSION RELATED REACTIONS (fever, flushing, rigors, myalgia). What should be done to prevent this?

Answer 14

conventional (deoxycholate)

need to premeditate 30 mins prior to administration

Question 15

What are the 5 options to premeditate pts with prior to receiving Amphtericin?

Answer 15

• HYDROCORTISONE
• IBUPROFEN
• MEPERIDINE
• acetaminophen
• diphenhydramine

Question 16

What TOXICITIES are associated with Amphotericin? (3)

Answer 16

• hypoKALEMIA
• hypoMAGNESEMIA
• acute kidney injury

Question 17

T/F The liposomal and lipid formulations were created to specifically prevent AKI caused by Ampho

Answer 17

TRUE

Question 18

What can be done to prevent AKI toxicity associated with Amphotericin?

Answer 18

500 mL of normal saline bolus BEFORE and AFTER EACH DOSE

Question 19

When should a pharmacist consider therapeutic drug monitoring(TDM)? (3)

Answer 19

• sensitive assay with QUICK LAB reporting
• well-established therapeutic RANGE
• inter-patient drug variability

Question 20

What 4 antifungals SHOULD have TDM?

Answer 20

• flucytosine
• Itraconazole
• voriconazole
• posaconazole suspension

Question 21

Tertiary care medical centers have a growing rate of …..

Answer 21

non-albicans candida

Question 22

What candida species?

-found on skin, GI, and genital tract

Answer 22

candida albicans

Question 23

What candida species?

-NOT AS susceptible to fluconazole

Answer 23

candida glabrata

Question 24

What candida species?

• sensitive to fluconazole
• seen in w/ TPNs often

Answer 24

candida parapsilosis

Question 25

What candida species?

-resistant to a LOT of drugs

Answer 25

candida auris

Question 26

What candida species?

-INTRINSICALLY RESISTANT to fluconazole

Answer 26

candida krusei

Question 27

Diagnosis for CANDIDIASIS is based on: (3)

Answer 27

• persisent signs of infection despite antibacterial agents
• risk factors
• blood cx POS for yeast

Question 28

T/F Yeast grown in a culture is a contaminate

Answer 28

FALSE: NEVER a contaminant

Question 29

Primary or Intrinsic resistance

Answer 29

resistant prior to anti fungal exposure

Question 30

secondary OR acquired resistance

Answer 30

• adaptations

- mutations

Question 31

______ is known as neutropenia

Answer 31

less than 1500 neutrophils

Question 32

_____ is known as SEVERE neutropenia

Answer 32

less than 500 neutrophils

decreases ability for the immune system to eradicate pathogens

Question 33

How do you calculate ABSOLUTE NEUTROPHIL COUNT (ANC)?

Answer 33

WBC * (% neutrophils + % bands)

Question 34

How long is tx for candidiasis?

Answer 34

at least 14 days

can possible de-escalate to diflucan after 5-7 days (if susceptible)

Question 35

What is the DOC for INVASIVE CANDIDIASIS (for neutropenic and non-neutropenic?

Answer 35

Echinocandin (Caspofungin, Micafungin, Anidulafungin)

neutropenic: also the option of Lipid Ampho B

Question 36

What is necessary for pts with CANDIDIASIS?

Answer 36

need an eye exam to make sure the pt DOES NOT have ocular disease (endophthalmitis)

Question 37

What is the RISK FACTOR for Aspergillosis?

Answer 37

immunosuppression

Question 38

What is key for diagnosis of Aspergillosis?

Answer 38

radiologic evidence (present OR halo sign on the CT of the chest in the lung)

Question 39

Postive glactomannan essay is indicative of?

Answer 39

probable aspergillosis

Question 40

What is the DOC for aspergillosis?

Answer 40

Voriconazole

Question 41

How long is the tx for Aspergillosis?

Answer 41

6-12 weeks

Question 42

What is the Voriconazole trough concentration 4-7 days after starting treatment GOAL for Aspergillosis?

Answer 42

1- 5.5 mg/L

greater than 1: better efficacy
less than 5.5: better safety

Question 43

RISK Factors for cryptococcosis (2)

Answer 43

*HIV/AIDS
(CD4 count less than 50 cells/mm)
*Immunosuppression

Question 44

Presentation of cryptococcosis in

• nonimmunosuppressed: _____________
• HIV/AIDs: _______

Answer 44

nonimmunosuppressed: pulmonary infection

HIV/AIDs: meningitis

Question 45

Diagnosis of cryptococcosis (2)

Answer 45

• CSF (lymphocytic)

* POS serum cryptococcal antigen

Question 46

Duration of histoplasmosis vs. blossomycosis

Answer 46

histoplasmosis = weeks
blastomycosis = months

Question 47

Steady state for ITRACONAZOLE is achieved around _______.And the target is ____________

Answer 47

2 weeks

0.5 mcg/mL - 10.0 mcg/mL