Systemic Mycoses and Atypical Organisms
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- Clinical presentations are protean and not pathogen-specific. Consider systemic mycoses in normal hosts with unexplained chronic pulmonary pathology, chronic meningitis, lytic bone lesions, chronic skin lesions, FUO, or cytopenias. In immunocompromised patients, besides the above presentations, the development of new pulmonary, cutaneous, funduscopic, or head and neck signs and symptoms should prompt consideration of these pathogens.
- The mycoses can often be identified by taking into account epidemiologic clues (many are geographically restricted), site of infection, inflammatory response, and microscopic fungal appearance. These infections can be complex and difficult to treat, and infectious disease consultation is recommended in all cases.
- Antifungal agents have variable doses, depending on severity of infection and the patient’s renal and hepatic function. Lipid formulations of amphotericin B (Amb) are preferred over the deoxycholate formulation owing to its more favorable toxicity profile. Significant drug–drug interactions exist between azole antifungals and many other medications, including immunosuppressant drugs. Loading doses of azole antifungals may be recommended in certain circumstances. Because treatment may be prolonged (weeks to months), it is recommended to check therapeutic levels of several antifungals to minimize toxicity. Levels may be checked for flucytosine, itraconazole, posaconazole, and voriconazole but not for isavuconazole or fluconazole.
- For details on treatment of fungal pathogens, Nocardia, and Actinomyces, see Table 14-11.Table 14-11: Treatment of Fungal Infections, , and
Pathogen and Therapy Additional Comments Candida spp.
- Thrush: Clotrimazole troche, nystatin suspension or Fluc 100 mg qday × 7–14 d
- Esophageal: Fluc 200 mg qday × 14–21 d
- Vaginal: Topical azole × 3–7 d or Fluc 150 mg PO once
- Frequent recurrence: Fluc 150 mg/wk × 6 mo
- Empirical treatment: Echinocandin
- Targeted: based on species and susceptibilities
- Average duration: 14 d
- Prophylaxis: May be beneficial in select patients with solid organ transplant, chemotherapy-induced neutropenia, or stem cell transplants.
- Candidemia: Treat from first negative blood culture. Perform ophthalmologic examination to rule out endophthalmitis. Central lines must be removed.
- Complicated infection: Duration may be extended if metastatic foci present or continued neutropenia.
Nonmeningeal, local, or mild–moderate disease
- Fluc 400 mg PO/IV qday × 6–12 mo
- Induction phase: Amb + 5-FC × 2 wk
- Consolidation phase: Fluc 400 mg PO qday × 8 wk
- Continuation phase: Fluc 200 mg qday × 6–12 mo
- Perform LP to rule out meningitis.
- HIV: Initiate ART 2–10 wk after starting Tx. Continue Fluc 200 mg PO qday for at least 12 mo and until CD4 count ≥100 for 6 mo.
- Check baseline CSF opening pressure. If ≥25 cm of CSF, reduce by 50% (up to 30 mL). Perform daily serial LPs if pressure elevated (≥25 cm H2O)
- Acute, mild–moderate: Observation. May Tx if symptoms >1 mo
- Acute, moderately severe to severe: Amb for 1–2 wk or until clinically improved, then Itra for 12 wk
- Chronic cavitary: Itra for 12–24 mo
- Mild–moderate: Itra for 12 mo
- Moderately severe to severe: Amb for 1–2 wk or until clinically improved, then Itra for 12 mo
- Antifungal treatment is not recommended
- Steroids may be considered for respiratory distress, hypoxemia, or severe mediastinal lymphadenitis.
- HIV: Itra 200 mg PO qday ppx in areas of high endemicity if CD4 count <150.
- PDH: Check urine antigen levels during/after Tx to monitor for relapse.
- TDM for itraconazole is recommended.
Pulmonary or Disseminated Extrapulmonary
- Mild to moderate: Itra for 6–12 mo
- Moderately severe to severe: Amb for 1–2 wk or until clinically improved, then Itra for 6–12 mo
- Immunosuppressed: Treat as severe disease for 12 mo
Suppression: Itra lifelong if continued immunosuppression
- For CNS disease, Itra or Vori can be used instead of Fluc.
- Uncomplicated pneumonia, asymptomatic pulmonary nodule: May not need Tx. If Tx, Fluc 400 mg PO qday for 3–6 mo
- Diffuse pneumonia: Amb for 1–2 wk or until clinically improved, then Fluc 400 mg PO qday for 12 mo
- Nonmeningeal: Fluc 800–1200 mg IV/PO qday
- Meningeal: Fluc 800–1200 mg IV/PO qday—if not improving, consider intrathecal Amb; followed by Fluc lifelong
- Can follow serum CF titers during/after treatment. Rising titers suggest recurrence.
- Consider surgery if pulmonary cavitary disease >2 yr or rupture.
- HIV: Continue Tx until CD4 count ≥250.
- After meningeal disease improves, lifelong Fluc.
- Hydrocephalus may require shunt for decompression.
Lymphocutaneous/Cutaneous: Itra × 3–6 mo
- Pulmonary/disseminated/osteoarticular: Amb for 1–2 wk or until clinically improved, then Itra for 12 mo
- Meningeal: Amb for 4–6 wk then Itra for 12 mo
- If no initial response, can use higher doses of Itra or add topical saturated solution of potassium iodide.
Pulmonary aspergilloma: Surgical resection or arterial embolization in cases of severe hemoptysis
Invasive pulmonary aspergillosis: Vori for at least 6–12 wk until lesions and immunosuppression resolve
Invasive sinonasal aspergillosis: Amb or Vori. Surgical debridement is adjunctive and often required for cure
Allergic bronchopulmonary aspergillosis: Itra or intermittent steroids may decrease exacerbations.
Prophylaxis: Posa in high-risk patients may be considered
- Amb to cover mucormycosis as initial therapy for sinus disease pending confirmation of diagnosis.
- If immunosuppression recurs, may need to restart ppx or Tx.
Cutaneous, Rhinocerebral: Aggressive surgical resection and debridement with clean margins followed + Amb at upper dose range until improvement
- Mortality is very high in immunosuppressed patients with disseminated disease.
- Posa and Isa are alternative Tx, after initial induction therapy with Amb.
Severe Infection (including CNS): Induction regimen typically includes two or three drugs including TMP-SMX, imipenem or linezolid for 4–6 wk with stepdown to oral therapy for 6–12 mo
- TMP-SMX is drug of choice but typically combined with other agents in disseminated disease.
- Use susceptibility results to guide treatment.
Penicillin G 18–24 million units IV per day × 4–6 wk then penicillin VK 1 g PO tid × 6–12 mo
- Surgery or drainage may be helpful in some cases.
- Clindamycin or doxycycline can be used if penicillin allergy.
5-FC, flucytosine; Amb, amphotericin B; ART, antiretroviral therapy; CF, complement fixation; CNS, central nervous system; CSF, cerebrospinal fluid; Fluc, fluconazole; Isa, Isavuconazole; Itra, Itraconazole; LP, lumbar puncture; Posa, posaconazole; ppx, prophylaxis; TDM, therapeutic drug monitoring; TMP-SMX, trimethoprim-sulfamethoxazole; Tx, treatment; Vori, voriconazole.