DOCSLIB.ORG

Treatment of Mucormycosis

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Treatment of Mucormycosis Treatment of Mucormycosis Anna Skiada, MD National and Kapodistrian University of Athens Greece ESCMID Online Lecture Library @ by author Financial disclosures • None pertaining to this presentation ESCMID Online Lecture Library @ by author Mucormycosis • Emerging fungal infection with high morbidity and mortality • Third cause of invasive fungal infections after Candida and Aspergillus • Second most common opportunistic mold infection (after aspergillosis) among patients with hematologic malignancies ESCMID Online Lecture Library @ by author Mucormycosis • Infection due to fungi of the class Zygomycetes, order Mucorales • Most common geni • Rhizopus • Mucor • Rhizomucor • Lichtheimia • Apophysomyces ESCMID• Cunninghamella Online Lecture Library @ by author Case Report • A 32-y.o. female patient was admitted to the hospital because of severe thrombocytopenia • Initial diagnosis: Idiopathic thrombocytopenic purpura • Methylprednisolone, 16mg tid • Danazol • One month later: Diagnosis of myelodysplastic syndrome ESCMID• Chemotherapy Online Lecture Library @ by author Case report (cont’ d) • A week later: The patient returns to the hospital with swelling over the left maxilla and intense pain • Examination of the oral cavity: normal • X-ray of sinuses: Sinusitis on the left side. ESCMID Online Lecture Library @ by author How should we manage the patient? 1. Start broad-spectrum antibiotics 2. Start an antifungal with activity against Mucorales 3. Arrange for a CT-scan of sinuses 4. Obtain an urgent ENT evaluation 5. Taper the dose of corticosteroids 6. 2, 3, 4 and 5 ESCMID Online Lecture Library @ by author How should we manage the patient? 1. Start broad-spectrum antibiotics 2. Start an antifungal with activity against Mucorales 3. Arrange for a CT-scan of sinuses 4. Obtain an urgent ENT evaluation 5. Taper the dose of corticosteroids 6. 2, 3, 4 and 5 ESCMID Online Lecture Library @ by author Problems in the diagnosis of mucormycosis The clinical signs and symptoms are non-specific Imaging signs are non-specific Various non-invasive tests (PCR, antigens etc) are not yet standardized Biopsy cannot always be performed due to severe thrombocytopenia in many cases Definite diagnosis is usually made in an advanced stage of the diseaseESCMID Online Lecture Library @ by author Early Initiation of Treatment Makes a Difference • 70 consecutive hematological patients • Start of treatment ≥6 days after diagnosis resulted in increased mortality at week 12 ESCMID Online Lecture Library @ by authorClin Infect Dis. 2008; 47: 503-509 Benefits of early diagnosis of Mucormycosis • Prevention of angioinvasion and dissemination of infection • Reduced need for extensive surgical resection • Reduced need for disfiguring surgery • Reduced suffering (invasion of sensory nerve fibers) • ImprovedESCMID outcome Online Lecture Library @ byAdapted author from Walsh TJ et al. CID suppl 2011 Underlying diseases- Risk factors • Diabetes mellitus • Hematologic malignancies (neutropenia) • Transplantation • Corticosteroids • AIDS • Hemochromatosis ESCMID Online Lecture Library • Occasionally, immunocompetent. @ by author Case report (cont’ d) • The symptoms were attributed to dental infection and amoxicillin was started. • Panoramic x-ray of teeth: No evidence of dental infection. • Metronidazole added to treatment. ESCMID Online Lecture Library @ by author Case report (cont’ d) • Three days later: Patient complains of diplopia, in addition to previous symptoms • Physical examination: black eschar on left side of hard palate, peripheral left facial nerve palsy and left abducens nerve palsy • Platelets: 28.000, neutrophils 5.000 ESCMID Online Lecture Library @ by author How should we proceed? 1. Obtain tissue from the eschar for direct microscopy, culture and histology 2. Start an anti-fungal active against Mucorales 3. Taper the corticosteroids 4. All of the above ESCMID Online Lecture Library @ by author How should we proceed? 1. Obtain tissue from the eschar for direct microscopy, culture and histology 2. Start an anti-fungal active against Mucorales 3. Taper the corticosteroids 4. All of the above ESCMID Online Lecture Library @ by author Imaging CT-scan: Opacity of left ethmoid and nasal cavity. No evidence of erosion. ESCMID Online Lecture Library @ by author Material taken from necrotic eschar, at the bedside, for culture and biopsy Direct microscopy of tissue: hyphae, non-septate, branching at right angles ESCMID Online Lecture Library @ by author Culture: Rhizopus sp. ESCMID Online Lecture Library @ by author Material taken from necrotic eschar, at the bedside, for histological examination ESCMID Online Lecture Library @ by author Case report (cont’d) • Liposomal amphotericin B, 5 mg/kg daily • Surgical debridement of hard palate ESCMID Online Lecture Library @ by author Antifungal drugs • Mucormycosis is resistant to most antifungal agents • Often encountered as a breakthrough infection in patients who are receiving antifungal agents against Aspergillus species (voriconazole) ESCMID Online Lecture Library @ by author Mucorales are Resistant to Most Antifungal Agents in vitro Inherently resistant to 5-flucytosine, ketoconazole, fluconazole, voriconazole Resistant to echinocandins? Limited in vitro activity of itraconazole and isavuconazole Amphotericin B is the most active agent Posaconazole has in vitro activity Cunninghamella are the most resistant spp Sun Q, Fothergill AW, McCarthy D et al. Antimicrob Agents Chemother. 2002; 46: 1581-1582 ESCMIDDannaoui E, Afeltra J,Online Meis J et al. Antimicrob Lecture Agents Chemother. 2002; Library 46: 2708-2711 Almyroudis N, Sutton DA, Fothergill A et al. Antimicrob Agents Chemother. 2007; 51: 2587-2590 @ byPerkhofer author S et al., Antimicrob Agents Chemother. 2009; 53:1645-47 Amphotericin B - Activity in vitro * AMB PCZ ITC % ≤1ug/mL % ≤0.5µg/mL % ≤0.5µg/mL Rhizopus sp (101) 100 80 62 Rhizopus arrhizus (20) 100 64 50 Rhizopus microsporus (12) 100 78 60 Mucor sp. (41) 94 70 57 Mucor circinelloides (6) 100 0 0 Rhizomucor sp.(5) 100 67 67 Absidia corymbifera (9) 100 100 100 Cunninghamella sp. (13) 63 75 29 ApophysomycesESCMID elegans Online(6) 100 Lecture83 Library80 * M38-A @ by author Almyroudis et al., AAC 07 Eight days later: MRI: Lesion extends in epidural space, forming an epidural abscess ESCMID Online Lecture Library @ by author What is the most important next step? 1. Perform radical surgery 2. Change liposomal ampho B to ABLC 3. Increase the dose of liposomal amphotericin B to 10 mg/kg 4. Add an echinocandin to ampho-B 5. All of the above ESCMID Online Lecture Library @ by author What is the most important next step? 1. Perform radical surgery 2. Change liposomal ampho B to ABLC 3. Increase the dose of liposomal amphotericin B to 10 mg/kg 4. Add an echinocandin to ampho-B 5. All of the above ESCMID Online Lecture Library @ by author Surgical treatment The patient underwent surgical debridement, which included: • enucleation of the left eye • resection of the left paranasal sinuses and • partial resection of ESCMIDthe left maxilla. Online Lecture Library @ by author Case report (cont’d) • One month later and while the patient was still receiving liposomal amphotericin B, a new necrotic eschar was noted. Tissue taken for biopsy: Hyphae still present. ESCMID Online Lecture Library @ by author How should we proceed? 1. Increase dose of liposomal amphotericin B to 10 mg/kg/d 2. Add an echinocandin to ampho-B 3. Start posaconazole 200mg qid 4. Start treatment with hyperbaric oxygen ESCMID5. Start treatment Online with deferasiroxLecture Library @ by author Echinocandins • Traditionally: no in vitro activity as single agents against agents of mucormycosis • However: Rhizopus oryzae expresses the gene encoding for the proteins of 1,3- β-D-glucan synthase complex • When combined with AmB lipid complex (ABLC), caspofungin was more active than ABLC alone or caspofungin alone, for the treatment of experimental, disseminated mucormycosis in ESCMIDdiabetic mice. Online Lecture Library @ by author Isavuconazole is under investigation in phase 3 studies on the safety and efficacy in treatment of fungal infections caused by Candida spp., Aspergillus spp., other filamentous fungi, rare molds, yeasts, and dimorphic fungi ESCMID Online Lecture Library @ by author Case report (cont’d) • New surgical debridement was performed • The dose of Ambisome was increased to 7mg/kg • Hyperbaric oxygen treatment was also started. • Cure after 4.5 months treatment with liposomal amphotericin B • Patient underwent reconstructive surgery. ESCMID Online Lecture Library @ by author Patient after reconstruction ESCMID Online Lecture Library @ by author ECIL-5 (2013) ECIL-5 (2013) Recommendation for first line (part 1) Management includes antifungal therapy, control of underlying conditions and surgery A II Antifungal therapy - AmB deoxycholate C II 1 - Liposomal AmB B II 1 - ABLC B II - ABCD C II 2 - Posaconazole CIII - Combination therapy CIII 1 Liposomal amphotericin B should be preferred in CNS infection and/or renal failure. 2 No data to support its use as first line treatment. May be used as an alternative when amphotericinESCMID B is absolutely Online contraindicated. Lecture Library @ by author ECIL-5 (2013) ECIL-5 (2013) Recommendation for first line (part 2) Management includes antifungal therapy, control of underlying conditions and surgery. A II Control of underlying condition A II 3 Surgery - rhino-orbito-cerebral A II - soft tissue A II - localized pulmonary lesion B III - disseminated CIII4 Hyperbaric oxygen
Load more

Recommended publications
  • Fungi-Rhizopus
    Characters of Fungi Some of the most important characters of fungi are as follows: 1. Occurrence 2. Thallus organization 3. Different forms of mycelium 4. Cell structure 5. Nutrition 6. Heterothallism and Homothallism 7. Reproduction 8. Classification of Fungi. 1. Occurrence: Fungi are cosmopolitan and occur in air, water soil and on plants and animals. They prefer to grow in warm and humid places. Hence, we keep food in the refrigerator to prevent bacterial and fungal infestation. 2. Thallus organization: Except some unicellular forms (e.g. yeasts, Synchytrium), the fungal body is a thallus called mycelium. The mycelium is an interwoven mass of thread-like hyphae (Sing, hypha). Hyphae may be septate (with cross wall) and aseptate (without cross wall). Some fungi are dimorphic that found as both unicellular and mycelial forms e.g. Candida albicans. 3. Different forms of mycelium: (a) Plectenchyma (fungal tissue): In a fungal mycelium, hyphae organized loosely or compactly woven to form a tissue called plectenchyma. It is two types: i. Prosenchyma or Prosoplectenchyma: In these fungal tissue hyphae are loosely interwoven lying more or less parallel to each other. ii. Pseudoparenchyma or paraplectenchyma: In these fungal tissue hyphae are compactly interwoven looking like a parenchyma in cross-section. (b) Sclerotia (Gr. Skleros=haid): These are hard dormant bodies consist of compact hyphae protected by external thickened hyphae. Each Sclerotium germinates into a mycelium, on return of favourable condition, e.g., Penicillium. (c) Rhizomorphs: They are root-like compactly interwoven hyphae with distinct growing tip. They help in absorption and perennation (to tide over the unfavourable periods), e.g., Armillaria mellea.
    [Show full text]
  • Comparative Evaluation of Isavuconazonium Sulfate
    Van Matre et al. Ann Clin Microbiol Antimicrob (2019) 18:13 https://doi.org/10.1186/s12941-019-0311-3 Annals of Clinical Microbiology and Antimicrobials RESEARCH Open Access Comparative evaluation of isavuconazonium sulfate, voriconazole, and posaconazole for the management of invasive fungal infections in an academic medical center Edward T. Van Matre1 , Shelby L. Evans2, Scott W. Mueller3, Robert MacLaren3, Douglas N. Fish3 and Tyree H. Kiser3,4* Abstract Background: Invasive fungal infections are a major cause of morbidity and mortality. Newer antifungals may provide similar efcacy with improved safety compared to older more established treatments. This study aimed to compare clinically relevant safety and efcacy outcomes in real world patients treated with isavuconazole, voriconazole, or posaconazole. Methods: This single center retrospective matched cohort study evaluated adults between January 2015 and Decem- ber 2017. The primary outcome was a composite safety analysis of antifungal related QTc prolongation, elevated liver function tests (> 5 times ULN), or any documented adverse drug event. Key secondary outcomes included: individual safety events, 30-day readmissions, magnitude of drug interactions with immunosuppressive therapy, and overall cost. Results: A total of 100 patients were included: 34 patients in the voriconazole group and 33 patients within each of the isavuconazole and posaconazole groups. The composite safety outcome occurred in 40% of the total cohort and was diferent between isavuconazole (24.2%), voriconazole (55.9%), and posaconazole (39.4%; p 0.028). Change in QTc (p < 0.01) and magnitude of immunosuppression dose reduction (p 0.029) were diferent between= the three groups. No diferences in mortality, length of stay, readmission, or infection= recurrence were observed between groups (p > 0.05 for all).
    [Show full text]
  • Candida Auris
    microorganisms Review Candida auris: Epidemiology, Diagnosis, Pathogenesis, Antifungal Susceptibility, and Infection Control Measures to Combat the Spread of Infections in Healthcare Facilities Suhail Ahmad * and Wadha Alfouzan Department of Microbiology, Faculty of Medicine, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait; [email protected] * Correspondence: [email protected]; Tel.: +965-2463-6503 Abstract: Candida auris, a recently recognized, often multidrug-resistant yeast, has become a sig- nificant fungal pathogen due to its ability to cause invasive infections and outbreaks in healthcare facilities which have been difficult to control and treat. The extraordinary abilities of C. auris to easily contaminate the environment around colonized patients and persist for long periods have recently re- sulted in major outbreaks in many countries. C. auris resists elimination by robust cleaning and other decontamination procedures, likely due to the formation of ‘dry’ biofilms. Susceptible hospitalized patients, particularly those with multiple comorbidities in intensive care settings, acquire C. auris rather easily from close contact with C. auris-infected patients, their environment, or the equipment used on colonized patients, often with fatal consequences. This review highlights the lessons learned from recent studies on the epidemiology, diagnosis, pathogenesis, susceptibility, and molecular basis of resistance to antifungal drugs and infection control measures to combat the spread of C. auris Citation: Ahmad, S.; Alfouzan, W. Candida auris: Epidemiology, infections in healthcare facilities. Particular emphasis is given to interventions aiming to prevent new Diagnosis, Pathogenesis, Antifungal infections in healthcare facilities, including the screening of susceptible patients for colonization; the Susceptibility, and Infection Control cleaning and decontamination of the environment, equipment, and colonized patients; and successful Measures to Combat the Spread of approaches to identify and treat infected patients, particularly during outbreaks.
    [Show full text]
  • Comparing the Effects of Combined Oral Contraceptives Containing Progestins with Low Androgenic and Antiandrogenic Activities on the Hypothalamic-Pituitary-Gonadal Axis In
    JMIR RESEARCH PROTOCOLS Amiri et al Review Comparing the Effects of Combined Oral Contraceptives Containing Progestins With Low Androgenic and Antiandrogenic Activities on the Hypothalamic-Pituitary-Gonadal Axis in Patients With Polycystic Ovary Syndrome: Systematic Review and Meta-Analysis Mina Amiri1,2, PhD, Postdoc; Fahimeh Ramezani Tehrani2, MD; Fatemeh Nahidi3, PhD; Ali Kabir4, MD, MPH, PhD; Fereidoun Azizi5, MD 1Students Research Committee, School of Nursing and Midwifery, Department of Midwifery and Reproductive Health, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic Of Iran 2Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic Of Iran 3School of Nursing and Midwifery, Department of Midwifery and Reproductive Health, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic Of Iran 4Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Islamic Republic Of Iran 5Endocrine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic Of Iran Corresponding Author: Fahimeh Ramezani Tehrani, MD Reproductive Endocrinology Research Center Research Institute for Endocrine Sciences Shahid Beheshti University of Medical Sciences 24 Parvaneh Yaman Street, Velenjak, PO Box 19395-4763 Tehran, 1985717413 Islamic Republic Of Iran Phone: 98 21 22432500 Email: [email protected] Abstract Background: Different products of combined oral contraceptives (COCs) can improve clinical and biochemical findings in patients with polycystic ovary syndrome (PCOS) through suppression of the hypothalamic-pituitary-gonadal (HPG) axis. Objective: This systematic review and meta-analysis aimed to compare the effects of COCs containing progestins with low androgenic and antiandrogenic activities on the HPG axis in patients with PCOS.
    [Show full text]
  • Tetracycline and Sulfonamide Antibiotics in Soils: Presence, Fate and Environmental Risks
    processes Review Tetracycline and Sulfonamide Antibiotics in Soils: Presence, Fate and Environmental Risks Manuel Conde-Cid 1, Avelino Núñez-Delgado 2 , María José Fernández-Sanjurjo 2 , Esperanza Álvarez-Rodríguez 2, David Fernández-Calviño 1,* and Manuel Arias-Estévez 1 1 Soil Science and Agricultural Chemistry, Faculty Sciences, University Vigo, 32004 Ourense, Spain; [email protected] (M.C.-C.); [email protected] (M.A.-E.) 2 Department Soil Science and Agricultural Chemistry, Engineering Polytechnic School, University Santiago de Compostela, 27002 Lugo, Spain; [email protected] (A.N.-D.); [email protected] (M.J.F.-S.); [email protected] (E.Á.-R.) * Correspondence: [email protected] Received: 30 October 2020; Accepted: 13 November 2020; Published: 17 November 2020 Abstract: Veterinary antibiotics are widely used worldwide to treat and prevent infectious diseases, as well as (in countries where allowed) to promote growth and improve feeding efficiency of food-producing animals in livestock activities. Among the different antibiotic classes, tetracyclines and sulfonamides are two of the most used for veterinary proposals. Due to the fact that these compounds are poorly absorbed in the gut of animals, a significant proportion (up to ~90%) of them are excreted unchanged, thus reaching the environment mainly through the application of manures and slurries as fertilizers in agricultural fields. Once in the soil, antibiotics are subjected to a series of physicochemical and biological processes, which depend both on the antibiotic nature and soil characteristics. Adsorption/desorption to soil particles and degradation are the main processes that will affect the persistence, bioavailability, and environmental fate of these pollutants, thus determining their potential impacts and risks on human and ecological health.
    [Show full text]
  • Ketoconazole (Systemic) | Memorial Sloan Kettering Cancer Center
    PATIENT & CAREGIVER EDUCATION Ketoconazole (Systemic) This information from Lexicomp® explains what you need to know about this medication, including what it’s used for, how to take it, its side effects, and when to call your healthcare provider. Brand Names: Canada APO-Ketoconazole; Ketoconazole-200; TEVA-Ketoconazole Warning This drug is not for use to treat certain types of fungal infections. This includes fungal infections of the skin, nails, or brain. Talk with the doctor. This drug must only be used when other drugs cannot be used or have not worked. Talk with your doctor to be sure that the benefits of this drug are more than the risks. Very bad and sometimes deadly liver problems like the need for a liver transplant have happened with this drug. Some people did not have a raised chance of liver problems before taking this drug. Most of the time, but not always, liver problems have gone back to normal after this drug was stopped. Call your doctor right away if you have signs of liver problems like dark urine, feeling tired, not hungry, upset stomach or stomach pain, light-colored stools, throwing up, or yellow skin or eyes. Blood tests will be needed to watch for any liver problems. Talk with your doctor. Taking this drug with certain other drugs may raise the chance of very bad and sometimes deadly heart problems like a heartbeat that is not normal. Do not take this drug if you are taking any of these drugs: Cisapride, disopyramide, dofetilide, dronedarone, methadone, pimozide, quinidine, or ranolazine. Ketoconazole (Systemic) 1/6 What is this drug used for? It is used to treat fungal infections.
    [Show full text]
  • Treatment of Peripheral Precocious Puberty
    View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by IUPUIScholarWorks Treatment of Peripheral Precocious Puberty Melissa Schoelwer, MD and Erica A Eugster, MD Section of Pediatric Endocrinology, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana Send correspondence to: 705 Riley Hospital Drive, Room 5960 Indianapolis, IN 46202 Phone: 317-944-3889 Fax: 317-944-3882 Email: [email protected] __________________________________________________________________________________________ This is the author's manuscript of the article published in final edited form as: Schoelwer, M., & Eugster, E. A. (2016). Treatment of Peripheral Precocious Puberty. In Puberty from Bench to Clinic (Vol. 29, pp. 230-239). Karger Publishers. http://dx.doi.org/10.1159/000438895 Peripheral Precocious Puberty Abstract There are many etiologies of peripheral precocious puberty (PPP) with diverse manifestations resulting from exposure to androgens, estrogens, or both. The clinical presentation depends on the underlying process and may be acute or gradual. The primary goals of therapy are to halt pubertal development and restore sex steroids to prepubertal values. Attenuation of linear growth velocity and rate of skeletal maturation in order to maximize height potential are additional considerations for many patients. McCune-Albright syndrome (MAS) and Familial Male-Limited Precocious Puberty (FMPP) represent rare causes of PPP that arise from activating mutations in GNAS1 and the LH receptor gene, respectively. Several different therapeutic approaches have been investigated for both conditions with variable success. Experience to date suggests that the ideal therapy for precocious puberty secondary to MAS in girls remains elusive. In contrast, while the number of treated patients remains small, several successful therapeutic options for FMPP are available.
    [Show full text]
  • Systemic Antifungal Drug Use in Belgium—
    Received: 7 October 2018 | Revised: 28 March 2019 | Accepted: 14 March 2019 DOI: 10.1111/myc.12912 ORIGINAL ARTICLE Systemic antifungal drug use in Belgium—One of the biggest antifungal consumers in Europe Berdieke Goemaere1 | Katrien Lagrou2,3* | Isabel Spriet4,5 | Marijke Hendrickx1 | Eline Vandael6 | Pierre Becker1 | Boudewijn Catry6,7 1BCCM/IHEM Fungal Collection, Service of Mycology and Aerobiology, Sciensano, Summary Brussels, Belgium Background: Reports on the consumption of systemic antifungal drugs on a national 2 Department of Microbiology and level are scarce although of high interest to compare trends and the associated epi- Immunology, KU Leuven, Leuven, Belgium 3Clinical Department of Laboratory demiology in other countries and to assess the need for antifungal stewardship Medicine, National Reference Centre for programmes. Mycosis, University Hospitals Leuven, Leuven, Belgium Objectives: To estimate patterns of Belgian inpatient and outpatient antifungal use 4Department of Pharmaceutical and and provide reference data for other countries. Pharmacological Sciences, KU Leuven, Methods: Consumption records of antifungals were collected in Belgian hospitals Leuven, Belgium between 2003 and 2016. Primary healthcare data were available for the azoles for 5Pharmacy Department, University Hospitals Leuven, Leuven, Belgium the period 2010-2016. 6 Healthcare‐Associated Infections and Results: The majority of the antifungal consumption resulted from prescriptions of Antimicrobial Resistance, Sciensano, Brussels, Belgium fluconazole and itraconazole in the ambulatory care while hospitals were responsible 7Faculty of Medicine, Université Libre de for only 6.4% of the total national consumption and echinocandin use was limited. Bruxelles (ULB), Brussels, Belgium The annual average antifungal consumption in hospitals decreased significantly by Correspondence nearly 25% between 2003 and 2016, due to a decrease solely in non-university hos- Berdieke Goemaere, Sciensano, Mycology pitals.
    [Show full text]
  • Sexually Transmitted Diseases Treatment Options
    Sexually transmitted disease (STD) treatment options PREFERRED & ALTERNATIVE OPTIONS Many clinical partners are operating in a limited capacity during the COVID-19 pandemic. Below are preferred (in clinic or other location where injections can be given) and alternative (when only oral medicines are available 1) treatments for STDs. Syndrome Preferred Treatments Alternative Treatments Follow-up Male urethritis syndrome Ceftriaxone 250mg intramuscular (IM) x 1 PLUS Men who have sex with men (MSM) and transgender women2: Patients should be counseled to azithromycin 1g PO x 1 Cefixime 800 mg PO x 1 PLUS doxycycline 100 mg PO BID x 7 days be tested for STDs once clinical Presumptively treating: care is resumed in the local If azithromycin is not available: doxycycline 100 Men who have sex with women only: gonorrhea clinics. Clients who have been mg PO BID for 7 days (except in pregnancy3) Cefixime 800mg PO x 1 PLUS azithromycin 1g PO x 1 referred for oral treatment If cephalosporin allergy5 is reported, gentamicin If cefixime is unavailable, substitute cefpodoxime 400mg PO q12h should return for 240mg IM x 1 PLUS azithromycin 2g PO x 1 x 2 for cefixime in above regimens4 comprehensive testing and screening and linked to services If oral cephalosporin not available or history of cephalosporin at that time. allergy5: azithromycin 2g PO x 1 If azithromycin is not available: doxycycline 100 mg PO BID for 7 days (except in pregnancy3) Patients should be advised to abstain from sex for 7 days Treatment typically guided by examination and For presumptive therapy when examination and laboratory following completion of Vaginal discharge syndrome treatment.
    [Show full text]
  • Antifungals, Oral
    Antifungals, Oral Therapeutic Class Review (TCR) July 13, 2018 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, digital scanning, or via any information storage or retrieval system without the express written consent of Magellan Rx Management. All requests for permission should be mailed to: Magellan Rx Management Attention: Legal Department 6950 Columbia Gateway Drive Columbia, Maryland 21046 The materials contained herein represent the opinions of the collective authors and editors and should not be construed to be the official representation of any professional organization or group, any state Pharmacy and Therapeutics committee, any state Medicaid Agency, or any other clinical committee. This material is not intended to be relied upon as medical advice for specific medical cases and nothing contained herein should be relied upon by any patient, medical professional or layperson seeking information about a specific course of treatment for a specific medical condition. All readers of this material are responsible for independently obtaining medical advice and guidance from their own physician and/or other medical professional in regard to the best course of treatment for their specific medical condition. This publication, inclusive of all forms contained herein, is intended to be educational in nature and is intended to be used for informational purposes only. Send comments and suggestions to [email protected]. July 2018 Proprietary Information. Restricted Access – Do not disseminate or copy without approval. © 2004-2018 Magellan Rx Management. All Rights Reserved. FDA-APPROVED INDICATIONS Drug Manufacturer FDA-Approved Indication(s) for oral use clotrimazole generic .
    [Show full text]
  • Fungemia and Cutaneous Zygomycosis Due to Mucor
    Jpn. J. Infect. Dis., 62, 146-148, 2009 Short Communication Fungemia and Cutaneous Zygomycosis Due to Mucor circinelloides in an Intensive Care Unit Patient: Case Report and Review of Literature Murat Dizbay, Esra Adisen1, Semra Kustimur2, Nuran Sari, Bulent Cengiz3, Burce Yalcin2, Ayse Kalkanci2*, Ipek Isik Gonul4, and Takashi Sugita5 Department of Infectious Diseases, 1Department of Dermatology, 2Department of Microbiology, 3Department of Neurology, and 4Department of Pathology, Gazi University School of Medicine, Ankara, Turkey, and 5Department of Microbiology, Meiji Pharmaceutical University, Tokyo 204-8588, Japan (Received February 6, 2008. Accepted December 26, 2008) SUMMARY: Mucor spp. are rarely pathogenic in healthy adults, but can cause fatal infections in patients with immuosuppression and diabetes mellitus. Documented mucor fungemia is a very rare condition in the literature. We described a fungemia and cutaneous mucormycosis case due to Mucor circinelloides in an 83-year-old woman with diabetes mellitus who developed acute left frontoparietal infarctus while hospitalized in a neuro- logical intensive care unit. The diagnosis was made based on the growth of fungi in the blood, skin biopsy cultures, and a histopathologic examination of the skin biopsy. The isolates were identified as M. circinelloides by molecular methods. This case is important in that it shows a case of cutaneous mucormycosis which developed after fungemia and provides a contribution to the literature regarding Mucor fungemia. Mucormycosis manifests as a rhinoorbitocerebral, pulmo- not associated with an invasive fungal disease. In addition, nary, gastrointestinal, cutaneous, or disseminated disease. The paranasal sinus and pulmonary computed tomography (CT) most frequently isolated pathogens are Rhizopus, Mucor, results were not indicative of any invasive fungal disease.
    [Show full text]
  • A Fresh Look at Echinocandin Dosing
    J Antimicrob Chemother 2018; 73 Suppl 1: i44–i50 doi:10.1093/jac/dkx448 We can do better: a fresh look at echinocandin dosing Justin C. Bader1, Sujata M. Bhavnani1, David R. Andes2 and Paul G. Ambrose1* 1Institute for Clinical Pharmacodynamics (ICPD), Schenectady, NY, USA; 2University of Wisconsin, Madison, WI, USA *Corresponding author. Institute for Clinical Pharmacodynamics (ICPD), 242 Broadway, Schenectady, NY 12305, USA. Tel: !1-518-631-8101; Fax: !1-518-631-8199; E-mail: [email protected] First-line antifungal therapies are limited to azoles, polyenes and echinocandins, the former two of which are associated with high occurrences of severe treatment-emergent adverse events or frequent drug interactions. Among antifungals, echinocandins present a unique value proposition given their lower rates of toxic events as compared with azoles and polyenes. However, with the emergence of echinocandin-resistant Candida species and the fact that a pharmacometric approach to the development of anti-infective agents was not a main- stream practice at the time these agents were developed, we question whether echinocandins are being dosed optimally. This review presents pharmacokinetic/pharmacodynamic (PK/PD) evaluations for approved echino- candins (anidulafungin, caspofungin and micafungin) and rezafungin (previously CD101), an investigational agent. PK/PD-optimized regimens were evaluated to extend the utility of approved echinocandins when treating patients with resistant isolates. Although the benefits of these regimens were apparent, it was also clear that anidulafungin and micafungin, regardless of dosing adjustments, are unlikely to provide therapeutic exposures sufficient to treat highly resistant isolates. Day 1 probabilities of PK/PD target attainment of 5.2% and 85.1%, respectively, were achieved at the C.
    [Show full text]