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Author: admin, 10.10.2015Endemic fungal infections can affect both healthy and immunocompromised patients and are seen in specific geographic locations around the world.
Opportunistic fungal infections primarily cause infections in patients who tend to be immunocompromised through a congenital or acquired disease process.
Candidiasis: Pulmonary pneumonia infection due to Candida species is rare and diagnosis can be difficult.
The following are therapeutic treatment options for fungal lung infections (TABLES 1 and 2). Triazole Antifungals: Available for several decades, triazole antifungals are well documented in the treatment of fungal infections. AmB Formulations: AmB is a macrocyclic polyene antifungal originally synthesized from Streptomyces.
As noted above, newer AmB delivery systems have greatly reduced infusion-related reactions and nephrotoxicity.
While the incidence of pulmonary fungal infections has increased over the years, advances in diagnostic techniques and treatments have improved. Acknowledgment: The authors would like to thank Edgar Gonzalez, PharmD, for his editorial recommendations. An increase in the number of patients with malignancy, HIV, hematologic disease, and conditions requiring immunosuppressive medications has contributed to an escalation of respiratory fungal infections.1 Luckily, enhancements in diagnostic measures and treatment modalities have expanded early detection of infection and available treatment choices. Infection results primarily from cutaneous contact with sporotrichosis.3,5 Pulmonary sporotrichosis and nodular lesions result from inhaling S schenckii. Aspergilloma (occurring in patients with cavitary lung disease) and allergic bronchopulmonary aspergillosis (identified in patients with a hypersensitivity to aspergillus antigens) are noninvasive manifestations.8 Once the cause is identified, the primary treatment for IPA is voriconazole.
An AmB formulation with or without flucytosine, followed by oral fluconazole, is the primary recommendation for severe symptomatic pulmonary cryptococcosis.
However, if a patient has underlying renal impairment, a lipid-based formulation (ABLC or L-AmB) is warranted. Despite these advances, patient outcomes remain poor owing to a lack of early infection identification. This article will discuss endemic and opportunistic respiratory fungal infections encountered, as well as currently available treatment options.
Immunocompetent infected hosts may not require treatment.1,6 Immunocompromised patients are treated with fluconazole or itraconazole. Polyenes bind to the ergosterols on the fungal cell membrane, creating channels, or pores, where potassium and other cellular components are released, leading to fungal death.19,20 As a result of chemical changes in the parent drug and new delivery systems, the harmful effects of AmB have been reduced.
Because of the high toxicity rate of C-AmB, AmB colloidal dispersion (ABCD) was formulated to reduce nephrotoxicity. An official American Thoracic Society statement: treatment of fungal infections in adult pulmonary and critical care patients.
Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America.
Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America.
Clinical practice guidelines for the management of sporotrichosis: 2007 update by the Infectious Diseases Society of America. Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America.
Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the Infectious Diseases Society of America. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America.
Liposomal amphotericin B: a review of its use as empirical therapy in febrile neutropenia and in the treatment of invasive fungal infections. A randomized, double-blind comparative trial evaluating the safety of liposomal amphotericin B versus amphotericin B lipid complex in the empirical treatment of febrile neutropenia. A double-blind, randomized, controlled trial of amphotericin B colloidal dispersion versus amphotericin B for treatment of invasive aspergillosis in immunocompromised patients. Current recommendations for efficacious treatment of mucormycosis include AmB formulations, posaconazole, and iron chelation therapy.
Because of hepatic metabolism, caution must be taken to avoid potential drug–drug interactions through the CYP450 system. With the expansion of antifungal treatment options, pharmacists should be aware of specific recommended doses, available drug formulations, drug–drug interactions, and potential side effects when assisting with the prescribing of antifungal agents.
If clinical improvement is not noted, failure of the first-line treatment should be considered and a second-line agent should be initiated.
Second-line agents indicated for the treatment of PCP include primaquine plus clindamycin, atovaquone, or IV pentamidine.
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