Id: Superficial Fungal Infections

Front 1

Name the types of superficial fungal infections.

Back 1

Fungal infections of the skin, hair, and nails:
tinea pedis (athlete's foot)
tinea curis (jock itch)
tinea corporis (trunk & extremities)
tinea capitis (scalp & hair follicles)
onychomycosis (fingernails, toenails)

Vulvovaginal Candidiasis (VVC)
Oropharyngeal Candidiasis (thrush)
Esophageal Candidiasis

Front 2

Treatment for fungal infections of the skin, hair and nails.

Back 2

• Topical (creams, sprays, lotions, shampoo) azoles or terbinafine applied to the affected area(s) for 1-4 weeks for tinea infections
• PO terbinafine, fluconazole, or itraconazole if extensive involvement, recurrent infections, or failure of topical therapy for tinea infections
• Onychomycosis – PO terbinafine or itraconazole for 3-6 months preferred; ciclopirox nail lacquer is an option for mild cases

Front 3

What is the pathogen or type of pathogen that causes fungal infections of the skin,hair and nails?

Back 3

Dermatophytes

Front 4

What is the primary pathogen that causes Vulvovaginal candidiasis?

Back 4

Candida albicans

Front 5

What is the primary pathogen that causes oropharyngeal and esophageal candidiasis?

Back 5

Candida albicans

Front 6

Candida albicans is the primary cause of which fungal infections?

Back 6

vulvovaginal, oropharyngeal, and esophageal candidiasis.

Also, candidemia.

Front 7

How do you treat Vulvovaginal candidiasis?

Back 7

• Uncomplicated- sporadic infection in healthy females
o Azoles in the form of vaginal suppositories, ovules, or creams for 1-7 days or nystatin vaginal tablet for 14 days
o PO fluconazole 150 mg x 1 dose
• Complicated-recurrent infections; may be very severe; diabetics, immunosuppressed patients or pregnant patients
o Vaginal azoles for 10-14 days
o PO fluconazole 150 mg Q 72hrs for 2-3 doses
o Pregnant – NO systemic azoles because they are pregnancy risk C
o Recurrent – induction therapy with vaginal azole or PO fluconazole for 14 days, followed by maintenance therapy with a daily vaginal azole or fluconazole 150 mg PO Q week

Front 8

How do you treat oropharyngeal candidiasis?

Back 8

• Advise the patient on proper oral hygiene- brushing teeth, flossing
• Local/topical therapy preferred for milder cases or patients without HIV
o Nystatin lozenge or swish and swallow QID for 7-14 days
o Clotrimazole 10 mg troche 5 x daily for 7-14 days
• Systemic therapy for more severe thrush or patients with HIV
o PO fluconazole 100-200 mg Q 24hr for 7-14 days after clinical improvement
o PO itraconazole solution 200 mg Q 24 hr for 7-14 days after clinical improvement

Front 9

How do you treat esophageal candidiasis?

Back 9

• 1st line – fluconazole
• Other options – itraconazole PO solution, voriconazole, echinocandins, amphotericin B products
• Treat for 14-21 days after clinical improvement

Front 10

What are the hosts' risk factors for candidemia?

Back 10

• Host factors
o HIV
o Hematologic malignancy
o Myelodysplastic syndromes
o Neutropenia/neutrophil dysfunction
o Malnutrition
o Poorly controlled diabetes
o Renal failure
o Pancreatitis
o Extensive burns
o GI perforation b/c candida colonizes the GI tract
o Mucosal colonization with Candida spp.
o Prematurity
o Age ≥ 65 yrs old

Front 11

What are the therapies/procedures that can put a person at risk for candidemia?

Back 11

o Vascular catheters (IV access is a great portal of entry for candida b/c candida is on your skin and will move from skin and into blood)
o Urinary catheters (IV access)
o Hemodialysis
o Broad spectrum antibiotics
o GI surgery
o ICU stay
o TPN total parenteral nutrition (IV access)
o Corticosteroid therapy suppress immune system
o Chemotherapy side effects: neutropenic, mucositis
o Solid organ transplantation (SOT)
o Hematopoietic stem cell transplantation (HSCT)
o Immunosuppressive therapy

Front 12

Pathogens that can cause candidemia include:

Back 12

Mainly Candida albicans.
• C. glabrata is the second most common cause of candidemia
o 5-10% of isolates resistant to fluconazole
o High % of isolates susceptible dose dependent to fluconazole
• C. tropicalis
o HSCT recipients
o Hematologic malignancies
• C. krusei (resistant to fluconazole)
o HSCT recipients with neutropenia
• C. parapsilosis
o Vascular catheters
o GI surgery
o TPN
o Prematurity
o Extensive burns

Front 13

C. glabrata

Back 13

2nd most common cause of candidemia

Front 14

C. tropicalis

Back 14

can cause candidemia; esp in
HSCT recipients
Hematologic malignancies

Front 15

C. krusei

Back 15

can cause candidemia; esp in HSCT recipeints with neutropenia
resistant to fluconazole

Front 16

C. parapsilosi

Back 16

vascular catheters, GI surgery, TPN, prematurity, extensive burns

Front 17

How do you treat candiduria?

Back 17

Remove urinary catheter (might be enough)
Otherwise, treat with Fluconazole PO
Amphotericin B deoxycholate continuous bladder irrigation

Front 18

Disseminated candidiasis (candidemia and/or its complications such as endophthalmitis, endocarditis, septic arthritis, osteomyelitis, hepatosplenic candidiasis)

Back 18

o 1st line options – fluconazole, echinocandins
o Alternatives – amphotericin B products, voriconazole
o If someone is on fluconazole for prophylaxis, and then they developed candiduria, then obviously don’t treat with fluconazole. Use something else!
o For candidemia – treat for at least 2 weeks after the first negative blood culture and resolution of signs and symptoms of infection
 For complications may need longer course of therapy
o Ophthalmologic examination to rule out endophthalmitis in all patients with candidemia; if you ever get candida in the blood, it may go to eye so check the eye!
 Treat with an azole (fluconazole has most vitreal (eye) penetration)

Front 19

What are the risk factors for Invasive Aspergillosis (mould)?

Back 19

• Severe immunosuppression
• Hematologic malignancy treated with chemotherapy
• HSCT (higher risk with allogeneic than autologous HSCT) Autologous= own cells are used; allogeneic= donor cells from somebody else; foreign cells will cause immune response so the patient will be placed on immune suppressants
o Neutropenia
o Age > 40 yrs old
o Underlying myelodysplasia
o GVHD Graft versus host disease- host cells will react to the foreign cells and need to be on immunesuppressants to prevent rejection but this also increases risk of fungal infection.
o Corticosteroid therapy
o Donor mismatch
• SOT Solid organ transplant patients are also on lifelong immune suppressants

Front 20

Which aspergillosis pathogen is the most common causative organism of invasive aspergillosis?

Back 20

Aspergillosis fumigatus

Front 21

Treatment for Invasive Aspergillosis

Back 21

• 1st line – voriconazole IV initially, followed by PO when patient clinically stable
• 2nd line – liposomal amphotericin B
• Salvage therapy if patients don’t respond – amphotericin B products, posaconazole, itraconazole, caspofungin, micafungin
• Treat for a minimum of 6-12 weeks
o If immunosuppressed, continue therapy throughout the period of immunosuppression
o Dose reduction or discontinuation of corticosteroids if possible
o Surgical management if indicated

Front 22

Treatment for Fusariosis.

Back 22

Treatment
• Surgical debridement of all infected necrotic tissue if possible
• Antifungal therapy
o 1st line option – voriconazole
o Alternatives – amphotericin B products, posaconazole, itraconazole

Front 23

Risk factors for Zygomycosis

Back 23

• Hematologic malignancy
• Allogeneic HSCT
• Diabetes
• IVDA- IV drug abusers
• Prematurity
• Deferoxamine therapy – some species acquire iron from the host for virulence and growth and have the ability to bind to the iron-deferoxamine complex

Front 24

Clinical Manifestations of Zygomycosis

Back 24

• Route of infection is by inhalation of spores
• Clinical manifestations
o Rhinocerebral manifestations: sinusitis with facial pain and swelling, unilateral headache, and bloody nasal discharge
o Pulmonary manifestations: fever, dyspnea, hemoptysis, and cavitation upon radiologic examination
o Invasive disease manifestations: tissue necrosis from angioinvasion and subsequent thrombosis
• Microscopic examination of infected tissue (if you can obtain them) is the standard for diagnosis

Front 25

Treatment for Zygomycosis

Back 25

• Surgical debridement of all infected necrotic tissue if possible depending on the location of the infection; rhinocerebral zygomycosis is in the eye, so if they removed the tissue, they will disfigure the face
• Antifungal therapy
o 1st line – amphotericin B products for a minimum of 8-10 weeks
o Salvage therapy – posaconazole these are the only drugs that have activity against these

Front 26

Treatment of Histoplasmosis

Back 26

Mild-moderate acute pulmonary infection
Usually self limiting so treatment not indicated unless symptoms for more than 1 month. Then, treat with PO itraconazole.