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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Recognize the host risk factors that predispose patients to invasive fungal infections

  • Identify the common patterns of antifungal resistance that affect the selection and dosing of antifungal therapy

  • Develop an appropriate treatment and monitoring plan for the management of invasive candidiasis

  • Compare and contrast the relative strengths and weaknesses of current systemic antifungal agents for the empiric treatment of an invasive fungal pathogen

  • Properly educate patients on potential drug interactions and adverse effects of triazole antifungal agents

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PATIENT PRESENTATION

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Chief Complaint

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"Patient in the intensive care unit has persistent fever despite broad-spectrum antibiotic therapy."

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History of Present Illness

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Steven Johnson is a 49-year-old male who presented to the emergency department 5 days ago with a history of worsening diffuse abdominal pain and vomiting. During the workup in the emergency department, a contrast-enhanced CT scan of the abdomen was ordered that showed inflammation and necrosis involving less than 15% of the pancreas. The patient was started on IV fluids, meropenem 1 g q 8 h plus vancomycin 1 g q 12 h. The patient underwent an exploratory abdominal laparotomy, which revealed inflammation of the common bile and stones in the gallbladder requiring cholecystectomy. The patient was subsequently transferred to the surgical ICU for postsurgical care where he remained in a guarded condition and extubated, but has developed a new fever in the last 24 hours on broad-spectrum antibiotic therapy.

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Past Medical History

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HTN

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Hyperlipidemia

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Family History

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Father had CAD and died of an MI at age 56. Mother is alive at age 70 with type 2 DM and osteoporosis.

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Social History

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Construction worker in Chicago. No recent travel or unusual exposures. Married and lives with wife of 18 years, has 2 kids, ages 12 and 15, and 2 pet dogs.

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Tobacco/Alcohol Substance Abuse

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Social drinker; occasional cigars; (−) illicit drug use

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Allergies/Intolerances/Adverse Drug Events

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None

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Medications (Current)

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Meropenem 1 g IV q 8 h

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Vancomycin 1 g IV q 12 h

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Normal saline, IV, 50 mL/h

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Fentanyl 75 mcg/h IV

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Lorazepam 0.05 mg/kg/h IV

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Tube feeds q 6 h via Dobhoff catheter as tolerated

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Pantoprazole 40 mg IV daily

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HCTZ 25 mg PO daily (on hold)

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Atorvastatin 40 mg PO daily (on hold)

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Acetaminophen 500 mg PO q 6 h PRN

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Diphenhydramine 50 mg PO q 4–6 h PRN

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Docusate sodium liquid 100 mg PO twice daily

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Review of Systems

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