week 2. Antiviral, antifungal, intro to parasites Flashcards
(190 cards)
1
Q
what was the first antiretrovural drug produced and when?
A
AZT in 1987
2
Q
explain the progression of HIV after infection?
A
you get primary infection –> where there is a rapid rise in viral load with a stark decrease in CD4 account.
However the immune system responds and there is a clinical latency where there the viral load is in balance.
However after some time the level of viral load increase while the CD4 count reduces –> opportunistic infection occurs
3
Q
what are the two types of Virus?
A
ones based on RNA and ones with DNA
4
Q
viruses that cause acute infection what are they based on?
A
RNA –> short lasting
5
Q
give examples of acute infection caused by virus
A
Influenza, measles, mumps, hepatitis A virus
6
Q
what are chronic infection based on?
A
DNA –> long lasting –> more stable and theredfore last a long time
7
Q
what are the two types of chronic infection by a virus?
A
latent and persistant
8
Q
give example of chronic latent virus’s?
A
Herpes simplex, Cytomegalovirus
9
Q
give example of persistant virus?
A
HIV, Hepatitis B virus, Hepatitis C virus
10
Q
what is a characteristic of persistant virus?
A
it replicates all the time
11
Q
how does HIV convert its RNA to DNA?
A
using reverse transcriptase
12
Q
what type of genetic information does Hep C have?
A
purerly RNA
13
Q
how does Hep C overcome the immune system and cause chronic infection?
A
it affects the liver and therefore evades the immune system and constantly evolving –> beating the immune system
14
Q
will you 100% die from hep B/C if you have it
A
no
15
Q
what does a virus consist of?
A
Nucleic acid (DNA or RNA) Protein (coat - structural, enzymes-non-structural) \+/- Lipid envelope
16
Q
HIV is Obligate intracellular parasites. What does this mean?
A
it cannot reproduce outside a host –> needs intracellular resources
17
Q
what is important about envelope structural proteins of HIV?
A
it is what allows HIV to invade cells
18
Q
what is the sequence of viral replication?
A
1) Virus attachment to cell (via receptor)
2) Cell Entry –> find the cell they can enter without harming it
3) Virus Uncoating ready for replication
4) Early proteins produced – viral enzymes
5) Replication
6) Late transcription/translation – viral structural proteins
7) Virus assembly
8) Virus release
9) Some virus kill the cell by lysis but not all do this and go and affect other cells
19
Q
what do virus’s encode and why are they important for treatment?
A
viruses encode unique proteins that are vital for virus replication and infectivity –> antiviral drugs target this for molecular inhibition
20
Q
what are the different types of polymerases involving VIrus’s?
A
DNA to DNA –>Eukaryotes , DNA viruses
DNA to RNA –> Eukaryotes ,DNA viruses
RNA to RNA–> RNA viruses
RNA to DNA –> Retroviruses (HIV), Hepatitis B virus
21
Q
what is azidothymidine?
A
Nucleoside Reverse Transcriptase Inhibitor (NRTI
22
Q
what does AZT do?
A
it inhibits reverse transcriptase in HIV and other retroviruses
23
Q
what was AZT first used for?
A
as a cancer drug but was to toxic
24
Q
what year was AZT used as a HIV treatment?
A
1985
25
what is AZT analogue of?
thymidine --> Oh is replace with 3 nitrogen atoms
26
what are the two types of NRTI analogue?
Purine analogue
| Pyrimidine analogue
27
what are the pyrimidine?
thymine and cytosine
28
give examples of pyrimidine analogue?
Thymidine analogues --> Zidovudine
| Cytosine analogues -->Lamivudine
29
what are the purines?
adenine and Guanidine
30
give example of purine analogue?
Abacavir
| Tenofovir
31
why is NRTI effective for hep B virus?
The virus contains reverse transcriptase enzyme
32
what NRTI are effective against hep B infection?
Lamividine
| Tenofovir
33
how does NRTI work?
by competing with reverse transcriptase for their interaction site with HIV genetic material
34
what is the difference between NRTI and NNRTI and how do NNRTI work?
NRTI looks similar to necleotides but NNRTI doesn't look like anything like nucleotides.
NNRT block reverse transcriptase by binding to a different part of the protein
35
name all the different protease inhibitors for HIV treatment?
```
Atazanavir
Darunavir
Fospamprenavir
Lopinavir
Nelfinavir
Ritonavir*
Saquinavir
```
36
which of the protease inhibitors increase the affect of other drugs?
ritonavir
37
what is the importance of protease in HIV?
HIV virus cuts proteins--> to form specific enzymes needed for it to function and replicate
38
what three parts of the HIV genome can be targeted in treatment?
core structural protein, envelope structural protein and viral enzymes
39
give example of the newer HIV drugs?
Fusion inhibitor
Integrase Inhibitors
Chemokine receptor antagonsits (
40
give an example foa fusion ihibitor and how it functions in respect to HIV treatment?
Enfuviritide (T20, given by IM injection as it is a peptide
41
give an example foa Integrase Inhibitors in respect to HIV treatment?
Raltegravir
42
how does Chemokine receptor antagonsits work?
it blocks the ability for HIV to bind to co receptors such as CCR-5 and CXCR4 --> which prevents the HIV virus to bind to CD4
43
what are the different combinations of Highly Active Antiretroviral Therapy (HAART)?
2 NRTIs + NNRTI
| 2 NRTIs + boosted PI
44
when is HAART given?
Started when CD4 falls
Aim to switch off virus replication
Taken life long
Suppression >10yrs achieved
45
what toxicity can be caused by HAART?
liver and kidney toxicity
46
in HAART why is 3 drugs used?
reduce the chance of the virus to become resistant --> very highly unlikely that the virus will mutate in such a way to become resistant to 3 different drugs
47
what mutation takes place in HIV to become resistant to Lamivudine?
M184V mutation
48
how many nucleotides does HIV contain?
9000
49
what mutation can make someone more resistant to HIV infection?
having a mutation to the gene that codes for CCR5 and CxCr4 will give someone greater resistance to HIV
50
what are inteferons?
are naturally occurring antivirals that are within the human body
51
what is the treatment of Hep C?
use of exogenous interferon --> can boost peoples antiviral affect
52
for howlong do you have to give interferons to treat Hep c?
3 to 12 months
53
what are the side effects of interferons?
make you feel depressed, flu like and is a injection
54
when will antivirals work on acute infection?
only if given very soon after infection --> as the bodies own immune system will start to kick in
55
what is Aciclovir used for?
For Rx of Herpes Simplex Virus (HSV) and Varicella Zoster Virus (VZV)
56
what is the structure of Aciclovir
Nucleoside analogue (phosphorylated by herpesvirus thymidine kinase)
57
what is Ganciclovir used for?
treatment of Cytomegalovirus (CMV)?
58
what is the treatment of influenza?
Oseltamivir and Zanamavir (neuraminidase inhibitors)
59
what is Ribavirin used for?
Hepatitis C virus and RSV
60
what is Interferons used for?
Hep B and C
61
what is a parasite?
An organism which lives in or on another organism (its host) and benefits by deriving nutrients at the other's expense.
62
DOES A PARASITE always cause disease?
no
63
what does Symbiosis mean?
living together; close, long term interaction between two different species
64
what does Mutualism mean?
an association in which both species benefit from the interaction
65
what does parisitism mean?
an association in which the parasite derives benefit and the host gets nothing in return but always suffers some injury
66
what does Commensalism mean?
an association in which the parasite only is deriving benefit without causing injury to the host
67
what is a definitve host in parasites?
Either harbours the adult stage of the parasite or where the parasite utilizes the sexual method of reproduction
68
what is the intermediate host in parasites?
Harbours the larval or asexual stages of the parasite
69
what is teh Paratenic host in parasites?
Host where the parasite remains viable without further development
70
what are the two types of parasites?
Protozoa --> Micro-parasites
| Helminths -->Macro-parasites
71
what does P.Falciparum cause and where is it found?
cause malaria and found in blood smears
72
what are the two types of helminths?
Platyhelminths-->(Flatworms)
| Nematodes --> (Round worms)
73
give example of Cestode and what is causes?
Taenia sp and it is tapeworm
74
what does Tissue nematode cause?
found in the bowel cause elephantiasis inflammation of the lymphatic system extreme swelling of arm and leg
75
what are the two types of parasite life cycle?
direct and indirect
76
what is direct life cycle?
invoves one type of species --> transmission through same species
77
how does indirect cycle work?
involves more than one specie --> there is a intermediate host
78
what is a complex indirect life cycle?
where there is more than one intermediate host
79
What type of parasite is Ascaris?
Macro-parasite (Helminth) - intestinal nematode
80
in what area is Ascaris most prevelant and what age group?
between ages of 3-8yr olds and also in areas of poor sanitation
81
how is Ascaris transmitted?
1 worm produces 200,000 eggs -> feaces of humans that contains eggs that contaminate water and ground.
82
how does Ascaris worm develop from a egg into a worm?
THe life cycle
Has a direct life cycle Worm in human intestine, eggs shed into the environment in faeces, eggs are then ingested, they travel in the portal circulation to the lungs where they then hatch and the worms are they swallowed and enter the intestine
83
what are the 2 different clinical stages of Ascaris?
lung migration and intestinal phase
84
In the lung migration of Ascaris what are the syptoms? (6)
Loefflers syndrome- dry cough, dyspnea, wheeze, haemoptysis, eosinophilic pneumonitis
85
what does eosinophilic pneumonitis mean?
is a disease in which a certain type of white blood cell called an eosinophil accumulates in the lung
86
what symptoms are present in the intestinal phase of AScaris?
Malnutrition
Migration – into hepatobiliary tree and pancreas
Intestinal obstruction
Worm burden
87
what is the treatment of Ascaris?
Albendazole and Benzimidazole
| Prevents glucose absorption by worm
88
what are the controls for AScaris?
Improve sanitation
Education
Community targeted deworming
89
what type of parasite are Schistosomiasis?
macro-parasites --> worms
90
where does Schistosomiasis occur and why?
predominantly in Africa because of the presence of Fresh water snails
91
What are the 4 stages of disease following schistosomiasis infection?
1) Swimmers itch (at sight of entry) 2) Katayama fever (can last a couple of weeks) 3) Chronic schistosomiasis (can persist for years) 4) Effects of eggs in distant sites: spine, lung
92
what does Schistosomiasis cause?
Causes chronic disease resulting in bladder cancer and liver cirrhosis
93
what is the intermediate host of Schistosomiasis ?
fresh water snails
94
what is the life cycle of Schistosomiasis ?
Eggs are shed in human stools or urine, the eggs hatch and the organism infects freshwater snails by penetrating snail tissue, organism matures in snail then released into water and penetrates human skin.
Pass into human circulation, migrate to portal blood in liver and mature into adults which migrate to the mesenteric venules of the bowel/rectum (laying eggs that circulate to the liver and shed in stools) and venous plexus of the bladder.
95
what is Katayama fever?
infection of the unirary tract and intestines --> through the blood --> weight loss --> loss of appetite
96
what specie of schistosomiasis affects the unirary tract and what is the symptoms?
S. haematobium
Haematuria
Bladder fibrosis and dysfunction
Squamous cell CA bladder
97
what specie of schistosomiasis affects the intestinal tract and what is the symptoms?
Hepatic/Intestinal (S. mansoni; S. intercallatum, S. japonicum; S. mekongi)
Portal Hypertension
Liver cirrhosis
98
how do you diagnose schistosomiasis that affects the urinary tract?
Terminal Stream Microscopy
| Serology
99
how do you diagnose schistosomiasis that affects the intestinal tract?
Stool Microscopy
Rectal Snip Microscopy
Serology
100
what is the treatment for schistosomiasis ?
Praziquantel (parazinoisoquinoline derivative) and treatment of long term complications
101
how does Praziquantel work?
40-60 mg/kg with food 3 doses 8-hourly
Mechanism unknown- increased ionic permeability tetanic contraction, detachment, death
Well absorbed, extensive 1st pass metabolism, inactive metabolites excreted in urine
102
how is schistosomiasis controlled?
Chemical treatment to kill snail intermediate hosts
Chemoprophylaxis
Avoidance of snail infested waters
Community targeted treatment, education and improved sanitation
103
what type of parasite causes Hydatid ?
Macro-parasite (Platyhelminth- Cestode-Tapeworm
104
what is the host of Hydatid?
human are accidental hosts
| usual host are sheep and dog
105
what causes Hydatid?
Echinococcus sp. (E. granulosus- cystic and E. multilocularis- alveolar)
106
what are the main point in the life cycle of Hydatid?
Dog has adult worm in intestines and sheds eggs in faeces These are ingested by a sheep, they hatch and the organism penetrates the sheep intestinal wall and travels to the liver or lungs where it forms a hyatid cyst. Cyst in sheep is ingested by a dog and cycle continues
107
what is the clinical signs of Hydatid?
```
Cysts: 70% liver, 20% lungs
May remain asymptomatic for years
Secondary bacterial infection
Cyst rupture- hypersensitivity
Aliphatic shock
Can see death
```
108
how is Hydatid diagnosed?
imaging and serology?
109
how to control Hydatid?
Regularly worm dogs to reduce egg production
Hand hygiene
Safe disposal of animal carcasses/products of conception
110
what type of parasite causes malaria?
Micro-parasite (protozoa- sporozoan
111
what are the species that cause malaria?
P. falciparum
P. vivax
P. ovale
P. malariae
112
which specie caues the most severe type of malaria?
P. falciparum
113
how is malaria transmitted?
by Anopheles (mosquito) as a vector
114
What is the life cycle of malaria?
Organism infected mosquito takes a blood meal from a human injecting the organism This travels to liver cells where it replicates until the cell bursts and the organism then infects RBCs, it can continue in a cycle in which it replicates in RBCs causing them to burst and release further organisms to infect further RBCs. It can also form gametocytes in RBCs which are ingested by another aedes mosquito when it takes a blood meal to form a new organism
115
what is the clinical presentation of malaria?
Fever & Rigors (alt. days with falciparum malaria, every 48hrs or 72hrs with benign malaria)
Cerebral malaria (confusion, headache, coma)
Renal failure (black water fever)
Hypoglycaemia
Pulmonary oedema
Circulatory collapse
Anaemia, Bleeding and DIC
116
what does the malaria parasite affect?
rupture red cells, block capillaries and cause inflammatory reaction
117
how do you diagnose malaria?
Thick and Thin Microscopy --> at least 3 to rule it out
Serology- detection of antigen in blood
PCR- detection of malarial DNA
118
what are the controls for malaria?
```
Insecticide spraying in homes
Larvicidal spraying on breeding pools
Filling in of breeding pools
Larvivorous species introduced in to mosquito breeding areas
Use of insecticide impregnated bed nets
Chemoprophylaxis
```
119
what is Cryptosporidiosis caused by?
Caused by Cryptosporidium parvum and hominis (micro-parasite, sporozoan)
120
what does Cryptosporidiosis cause?
diarrhoeal disease
121
how is Cryptosporidiosis spread?
human to human transimission --> faecal-oral spread.
122
what animals act as reservoir of Cryptosporidiosis?
cattle, sheep, goats
123
what conditions promote Cryptosporidiosis?
warm and tropical places
124
what is the clinical presentation of Cryptosporidiosis?
Watery diarrhoea with mucus (no blood)
| Bloating, cramps, fever, nausea, vomiting
125
how long does Cryptosporidiosis last for and when is it severe?
Usually self-limiting (last up to 2 weeks)
Can be severe in:
very young
very old
Immuno-compromised (60% HIV patients infected go on to chronic infection- can loose up to 25 litres fluid/day)
126
who are at risk of human to human spread of Cryptosporidiosis ?
```
Regular users of swimming pools (can be resistant to chlorine)
Child care workers and parents
Nursing Home residents/carers
Healthcare workers
Travellers
```
127
who are at risk of animal to human spread of Cryptosporidiosis ?
Backpackers, Campers, Hikers
Farm workers
Visitors to farms/petting zoos
Consumers of infected dairy products
128
what is the diagnosis of Cryptosporidiosis- ?
Faeces sample:
Acid fast staining
Antigen detection by EIA Enzyme Immunoassays
129
what are the treatments for Cryptosporidiosis?
Symptomatic:
Rehydration etc.
Nitazoxanide
For immunocompromised:
Paromomycin (to kill parasite)
Nitazoxanide (effectiveness is unclear)
Octreotide (reduce cramps and frequency)
HIV patients, HAART should be quickly initiated
130
how can Cryptosporidiosis be controlled?
Human-Human:
Hand hygiene
Filter or boil drinking water (cf. chlorination)
Isolate symptomatic patients in healthcare setting
Ensure symptomatic children are kept away from school
Animal-Human:
Pasteurise milk and dairy products
Boil or filter drinking water if camping
131
what are the two main types of fungi?
Filamentous fungi
| Yeasts
132
what characterstic does Dimorphic fungi have?
can be a in a yeast form or the filmanetous form depending on the environment they are in
133
what does Pneumocystis jiroveci cause?
it causes pneumonia in immunesupressed patients
134
what are all the possible targets of antifungals?
```
cell wall
DNA synthesis
mitosis
cell membrane
protein synthesis
```
135
what is the cell membrane of a fungus made up of and why is this key to antifungal agents?
it is made up of Ergosterol --> human cell mebrane contain cholesterol. Therefore antifungal agents can target Ergosterol without damaging human cells
136
what is the cell wall of antifungals made up of?
ß-1,3 glucan
137
where is Ergosterol found and what does it regulate?
Forms clusters within the phospholipid bilayer of the cell membrane
Has a role in the regulation of membrane permeability
138
what is the importance of ergosterol?
Required for normal growth and function of the fungal cell wall, hence fungal viability
139
what is the route of the formation of ergosterol?
squalene --> lanosterol --> ergosterol
140
what are the two main enzymes involved in the formation of ergosterol? At what point do they act?
Squalene epoxidase --> involved in squalene converting to lanosterol
Lanosterol 14a demethylase --> involved in lanosterol converting to ergosterol
141
what is ß-1,3 glucan mae up of?
large polymer of UDP glucos
142
how much of the cell wall is made up of ß-1,3 glucan
50-60% of the dry weight of fungal cell wall is made up of ß-1,3 glucan
143
what synthesises ß-1,3 glucan?
ß-1,3 glucan synthase
144
what does ß-1,3 glucan form?
forms a fibrous network on the inner surface of the cell wall
145
what are the antifungal classes?
Polyenes
Allylamines
Azoles
Echinocandins
146
what is the mode of action of polyenes?
Association with ergosterol in a physical way
Formation of pore-like molecular aggregates
Loss of membrane integrity and leakage of K+
Cell death --> don’t have a proper cell membrane integrity
147
give exampls of polyenes?
Amphotericin B
| Nystatin
148
what is the problem of Nystatin ?
it is very toxic and can't be given by Iv --> only orally and small amounts
149
what is the spectrum of activity of Amphotericin B?
Most fungi of medical importance
| Aspergillus spp., Candida spp., Cryptococcus spp.
150
what are the adverse affects of Amphotericin B?
allergic reaction and nephrotoxicity
| It is not 100% selective to fungal cells can affect human cells --> if patient is ill then can also damage the kidneys
151
why is the Lipid-associated AmB?
it is less toxic to kidney cells
152
what are the different formations of AmB?
Liposomal AmB (L-AmB)
AmB lipid complex (ABLC)
AmB colloidal dispersion (ABCD)
153
how is AmB used clinically? How is it administrated?
Not absorbed orally so it is administered parenterally IV
Used for Serious/systemic infections
e.g. aspergillosis, candidiasis, cryptococcosis
Not used, if possible, in patients with existing nephrotoxicity
154
what is Nystatin used for?
Superficial infections
e.g. oral/vaginal candidiasis
tropical administration
155
how does Allylamines work? Give a example of Allylamines.
Mode of action --> Inhibit ergosterol synthesis (Squalene epoxidase)
Examples
Terbinafine
156
what is the spectrum of terbinafine?
Broad spectrum of activity in vitro but in practice only one type of infection
157
what is the adverse affects of terbinafine?
Liver toxicity
| Jaundice, hepatitis – rarely fatal
158
what is the clinical use of terbinafine?
Dermatophyte infections (superficial fungal infections)
159
what is the tropical use of terbinafine?
Athletes foot (tinea pedis), tinea corporis, tinea cruris
160
what is the systemic (oral) use of terbinafine?
Scalp ringworm (tinea capitis), onychomycosis
161
what is onychomycosis?
nail infection
162
what is 1)tinea corporis, 2)tinea cruris?
1) infection of the arms and legs
| 2) infection of the groin
163
what is the structure of azoles?
Synthetic compounds containing a 5-membered azole ring
164
what are the two types of azoles and state how many nigrtogen atoms they have
Imidazoles --> Two nitrogen atoms
| Triazoles --> Three nitrogen atoms
165
which azoles type is the new one?
imidazoles --> is old one
| Triazoles --> new one
166
how dos azoles work?
Inhibit ergosterol synthesis
Lanosterol 14α-demethylase -->inhibit this enzyme
Build up of non-ergosterol 14α-sterols in cell membrane --> don’t function properly and therefore fungus can’t become functioning fungal
167
what is the spectrum of azoles?
Complex, varies between drugs
Essentially broad spectrum
Yeasts and filamentous fungi
168
what azole is ineffective against Aspergillus?
Fluconazole
169
what type of drug is Ketoconazole and why was it stopped?
it is a imidazoles --> very toxic and causes hepatitis
170
give examples of imidazoles --> state the most common one?
Clotrimazole--> most common and used for vaginal thrush
Miconazole
Ketoconazole --> shampoo format
171
give examples of Triazoles--> state the most common one?
```
Fluconazole --> common
Itraconazole--> common
Voriconazole --> common
Posaconazole
Isavuconazole
```
172
what is the adverse effect of azoles?
Hepatotoxicity liver problem
Mild liver enzyme abnormalities (e.g. 7% with fluconazole)
Life-threatening hepatitis (e.g. 1/10 000 patients with ketoconazole)
173
what drug interaction does azole have?
Inhibition of cytochrome P-450 enzymes
| Increases concentration of all drugs metabolised by Cy P-450 enzymes
174
what is the antifungal spectrum for triazoles drugs?
Fluconazole --> only yeast
Itraconazole/ voriconazole --> yeast and Aspergillus spp.
Posaconazole/isavuconazole --> yeast, Aspergillus spp and Mucoraceous moulds
175
what is the clinical use of Imidazoles?
Superficial infections (topical administration)
Candidiasis --> vaginal thrush ( treatment -->Clotrimazole)
Dermatophyte infections
176
what is the clinical use of triazole?
Systemic infections (oral/parenteral administration)
Aspergillosis (used in treatment and occasionally as prophylaxis)
Candidiasis (fluconazole)
177
what is the mode of action of Echinocandins ?
Inhibition of β-1,3-glucan synthase
| Construction of severely abnormal cell wall
178
give examples of Echinocandins ?
Anidulafungin --> most common
Caspofungin
Micafungin
179
what is the spectrum of actiity of Echinocandins?
Aspergillus and Candida spp.
180
what are the adverse affects of Echinocandins?
Minimal
| e.g. skin rash, nausea, vomiting, headache, diarrhoea in common with any other drug
181
what is the clinical use of Echinocandins?
Parenteral formulations only --> only IV
only treat serious fungal infection --> so really only treat Aspergillus
and Candida spp
182
what is 5-fluorocytosine (5-FC)?
Synthetic analogue of cytosine (nucleotide) --> initially anti cancer drug but now used as a antifungal agent
Pyrimidine nucleoside
183
what is the mode of action of 5-fluorocytosine (5-FC)?
Entry into cell requires fungal cytosine permease--> selective toxicity
Converted to 5-fluorouracil and 5-fluorodeoxyuridine monophosphate --> Inhibit RNA/protein synthesis and DNA synthesis
184
spectrum of activity of 5-fluorocytosine (5-FC)?
yeast only --> Candida and Cryptococcus spp.
185
what is the adverse affect of 5-fluorocytosine (5-FC)?
Bone marrow suppression
Selective toxicity is incomplete ( gets to human a bit)
5-fluorouracil (5FU) is an anti-cancer drug
186
clinical use of 5-fluorocytosine 5-FC?
```
clinical use is exteremly limited -->
Cryptococcal meningitis (in combination with AmB)
```
187
what is the mode of action, spectrum of activity, adverse affect and clinical use of Griseofulvin?
Mode of action -->Inhibition of fungal mitosis
Spectrum of activity --> Dermatophytes
Adverse effects -->Minimal
Clinical use --> Dermatophyte infections in children requiring systemic treatment --> e.g. kerion, onychomycosis
188
what are the reasons for therapeutic drug monitoring
To minimize toxicity -->Level should remain below a threshold value
To maximize efficacy --> Level should exceed a threshold value
189
what are the antifungal agents that need therapeutic drug monitoring TDM?
Itraconazole
5-fluorocytosine
Voriconazole
190
why does Itraconazole, 5-fluorocytosine and Voriconazole needs TDM?
itraconazole --> if given to low of a dose then won't have a affect
5-fluorocytosine --> V. toxic if have a build up
Voriconazole --> liver toxicity but also a level of use beneath it which it is not effective
