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7 Cases Fungal
7 Cases Fungal
• Respiratory failure
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10. Haemodialysis Molecular diagnosis
11. Glucocorticoid use or chemotherapy PNA FISH
for cancer T2 Candida Panel
12. Candida colonization, particularly if
multifocal (colonization index >0.5 or
corrected colonization index >0.4)
13. Suspected Cryptococcal
infection/Aspergillosis
Day 7
• Mortality – 30-60%
Is this drug is
Early initiation effective and
PK/PD Optimization safe ?
Fungicidally
Source control
Adequate duration
PK/PD of antifungal agents Side effects
Drug Characteristics
Drug Characteristics
Site of Action
Flucytosine
What is your therapeutic plan in this case?
• Echinocandins and the lipid formulations of AmB are not able to achieve
adequate concentrations in urine and should not be used to treat UTIs.
Case Discussion 2
CASE
• Mrs AB, 59 year old female
• Known SLE on steroids, Azathioprine
• Developed fever, dyspnea – since last 7 days , worsening since 3 days
• Surveillance ET secretions
• Aspergillus fumigatus
• CXR
• widespread airspace infiltrates (ALI)
• Is the Aspergillus culture relevant?
What would you do next?
Would you treat?
MANNAN ANTIGEN/ ANTI- MANNAN Candida species only 83% / 86% when both 1. Unclear cut off values
ANTIBODY tests are used in
combination 2. Sensitivity varies depending on
species
NUCLEIC ACID PCR All species but Only available 96 % / 97% 1. Can detect deep seated infections
currently for Candida spp
( T2 CANDIDA/ SEPTIFAST) 2. Unavailable for many species
Aspergillus and some other Serum : 71% / 89% 1. False positives with plasmalye, beta
molds lactams
GALACTOMANNAN BAL : 76-88% / 87-
100%
m
AJRCCM . 2008;177: 27-34.
• 110 ICU admission, IPA by EORTC/MSG criteria
c ta
• 1/3 hematological malignancy interpret with care
b a
z
• BAL GM probably useful; Serum GM probably not
a o
- t
il l in
a c
i p er
: P
a re
ew
B
Imaging
• CT
• Frequently absent
• Halo sign, air crescent sign
and nodules much more
common in neutropenic
patients
• Difficult to interpret with
ARDS
Alternative treatment
First line treatment • Lipid amphotericin B 3-5 mg/kg IV every
• Voriconazole 6 mg/kg IV first two dose 24 hourly or
then 4 mg/kg bd IV or 200 mg bd
• Caspofungin 70 mg loading f/by 50 mg IV
OD or
Oral/IV
Q- Most patients with aspergillosis are
Mainly for Aspergillus
on immuno- suppressants – how does
Step down oral therapy for:-
giving Voriconazole affect the same ?
C. Krusei
- Increased concentrations of cyclosporine and C. glabrata
tacrolimus have been associated with Drug- drug interactions are
common with voriconazole
nephrotoxicity, and so patients should be
Caution:- IV voriconazole is not
monitored for the development recommended in patients with a
of abnormal renal function. creatinine clearance <50 ml/min
Empirical dose reductions are recommended b/o cyclodextrin accumulation.
• Likely Mucor
• Rx- Empirical liposomal amphotericin B
Q- What are the predisposing factors for Mucormycosis?
Development of
hypokalemia & Inhibitory effects on
Decreased blood flow & GFR
Hypomagnesaemia, Type I erythropoietin secretion
RTA & Nephrogenic DI
Conclusion:-
Continuous infusions of amphotericin B reduce nephrotoxicity and
side effects related to infusion without increasing mortality.
• 4-6 months
• Till repeat imaging shows halt in progress of the disease
• Other options of Rx if amphotericin cant be given
T/t of Mucormycosis
• Liposomal Amphotericin B or • Oral Posaconazole – delayed release • For patients who do not respond to
Amphotericin B lipid complex @ tablets (300 mg every 12 hours on or cannot tolerate amphotericin B
5 mg/kg , increase up to 10 the first day then 300 mg once daily)
mg/kg taken with food if possible or • IV Posaconazole - loading dose of
300 mg every 12 hours on the first
• Renal mucormycosis – Drug of • Isavuconazole – loading doses of 200 day, followed by a maintenance
dose of 300 mg every 24 hours
choice is Amphotericin B mg (i.e. two capsule) of oral
thereafter
Deoxycholate Isavuconazole should be given every
8 hourly for six doses, followed by • Isavuconazole should be given as a
• Note :- Lipid formulations of 200 mg od loading dose of 200 mg IV or orally
Amphotericin B do not penetrate every 8 hours for the first six doses
the kidney or achieve measurable followed by 200 mg IV or orally
concentration in Urine every 24 hours thereafter.
Thank you