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LEARNING OBJECTIVES

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LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Differentiate epidemiologic differences and host risk factors for acquisition of primary and opportunistic invasive fungal pathogens.

  2. Recommend appropriate empiric or targeted antifungal therapy for the treatment of invasive fungal infections.

  3. Describe the components of a monitoring plan to assess effectiveness and adverse effects of pharmacotherapy for invasive fungal infections.

  4. Evaluate the role of antifungal prophylaxis in the prevention of opportunistic fungal pathogens.

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KEY CONCEPTS

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  • Image not available. The diagnosis of endemic fungal infections is often prompted by a patient history of prolonged infectious symptoms, travel or residence in an endemic area, and/or participation in activities that result in exposures to soil contaminated by endemic fungi.

  • Image not available. The approach to antifungal therapy in patients with endemic fungal infections is determined by the severity of clinical presentation, the patient's underlying immunosuppression, and potential toxicities and drug interactions associated with antifungal treatment.

  • Image not available. Commensal or environmental fungi that are typically harmless can become invasive mycoses when the host immune defenses are impaired. Host immune suppression and risk for opportunistic mycoses can be broadly classified into three categories: (a) quantitative or qualitative deficits in neutrophil function, (b) deficits in cell-mediated immunity, and (c) disruption of integument and/or microbiologic barriers.

  • Image not available. It is important to be familiar with the relative epidemiology and frequency of non-albicans Candida species in the institution or intensive care unit (ICU) before selecting empiric antifungal therapy for invasive candidiasis, as fluconazole is not recommended for the treatment of C. glabrata and C. krusei infections

  • Image not available. If a patient is nonneutropenic, clinically stable (i.e., normotensive with relatively normal organ function), and has never received prior azole therapy, fluconazole 12 mg/kg/day loading dose followed by 6 mg/kg/day is still considered an appropriate first-line therapy for invasive candidiasis in many centers until speciation of the Candida isolate is confirmed.

  • Image not available. Clinical trials performed by the National Institute of Allergy and Infectious Diseases (NIAID) Mycoses Study Group demonstrated that 2 weeks of induction antifungal therapy with combination amphotericin B (0.7 mg/kg/day) plus flucytosine (100 mg/kg/day) achieved the highest clinical cure rates with reduced toxicity for cryptococcal meningitis.

  • Image not available. Immunocompromised patients on fluconazole with progressive sinus or pulmonary disease by radiography should be considered to have a possible mold infection and receive empiric antifungal therapy directed (at minimum) against Aspergillus species.

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Invasive fungal infection or invasive mycoses are general terms for diseases caused by invasion of living tissue by fungi. Unlike superficial mycoses (see Chap. 83), invasive mycoses invade internal organs, can disseminate throughout the body, and are associated with high rates of morbidity and mortality, particularly in the immunocompromised host. Invasive fungal infections are broadly categorized as either primary or opportunistic invasive mycoses. Primary invasive fungal infections are caused by fungal spores or conidia in the soil that, when disturbed, can become aerosolized and inhaled leading to infection, even in an immunocompetent patient. Because these fungi are often ...

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