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Fungal Infections – Kara Birrer, PharmD Diagnosis • Culture – single best tool • Smear of body fluids and/or tissues • Skin test – coccidiodin antigen • Histopathology or special stains of biopsy specimens • Serology – only moderately helpful Types of Invasive Fungal Infections • Yeasts – Candida spp. – Cryptococcus neoformans • Aspergillus spp. • Fusarium spp. • Mucor spp. • Other fungi 7 8 Emerging Fungal Pathogens Yeast Candida spp. Cryptococcus spp. Trichosporium Zygomycetes Fungus Mold Mucor spp. Pheohyphomycoses Others Black mold Dematiaceous Wangiella spp. Ashley ESD. An update on antifungal therapy. FSHP 2006 Septate Dimorphic Histoplasmosis Blastomycosis s Coccidomycosis Hyalohyphomycoses Aspergillus spp. Fusarium spp. Paecilomyces spp. 9 Yeast – Candida spp. • Most common fungal pathogen • Opportunistic pathogens • 4 th most common nosocomial bloodstream infection • Portals of entry: – Gastrointestinal tract – Central venous catheters • C. albicans versus non-C. albicans Bustamante CL. Cur Opin Infect Dis. 2005; 18:490. 10 Yeast – Candida spp. • Most common types of infections – Mucosal candidiasis (thrush) – Candida esophagitis – Candida pneumonia – Candidemia • 25-50% of nosocomial candidiasis • 20% associated with central venous catheters Yeast – Candida spp. • C. albicans = 80-90% of oropharyngeal colonization • Also common fecal normal flora • C. albicans & C. glabrata account for 70% of all Candida infections • Drug of Choice (DOC): Candida spp. dependant 11 www.asm.org/Division/c/fungi.htm 12 01/14/2009 2
Fungal Infections – Kara Birrer, PharmD Yeast – Candida spp. Yeast – Candida spp. Treatment • At ORMC (July 2006 – June 2007 Sterile Sites): – 52% C. albicans – 48% C. non-albicans • Other Candida spp concerns: – Biofilm formation on indwelling catheters – C. albicans resistance to fluconazole 13 Ostrosky-Zeichner L, et.al. Crit Care Med. 2006; 34(3):857. 14 Yeast – Candida spp. Treatment C. krusei C. glabrata Echinocandin Candida spp. C. albicans Fluconazole – st infection 1 st Echinocandin nd infection –2 nd C. dubliniensis C. guilliermondii C. lusitaniae C. parapsilosis C. tropicalis Fluconazole Patient Case - DB • RLQ Abscess Cx: (results available POD#15) – Candida (Torulopsis) glabrata – Candida tropicalis • Is the fluconazole enough Concerns • POD# 15 – – Discontinue fluconazole – Caspofungin 70mg IV x 1, then 50mg IV daily Ostrosky-Zeichner L, et.al. Crit Care Med. 2006; 34(3):857. 15 16 Yeast – Cryptococcus spp. • Cryptococcus neoformans • Source – soil contamination with pigeon droppings • Portal of entry – inhalation • Primarily infects the central nervous system – meningoencephalitis Yeast – Cryptococcus spp. • Nearly always associated with an immunocompromised state – 6-10% of HIV+ patients in the US will develop • Treatment: – Amphotericin B + Flucytosine x 2 weeks – Followed by Fluconazole 400mg po daily x 6 weeks Sobel JD, et.al. Contemporary Diagnosis & Management of Fungal Infections. 2003, pp.123. 17 Sobel JD, et.al. Contemporary Diagnosis & Management of Fungal Infections. 2003, pp.123. 18 01/14/2009 3
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