Fast Five Quiz: Are You Familiar With Conditions Responsible for Recent Outbreaks?

Richard H. Sinert, DO

Disclosures

January 18, 2018

Alternative regimens may be considered in patients who are intolerant to the treatment regimens or when the infection is refractory to the antifungal regimen. The combination of amphotericin B and flucytosine has been recommended in several special situations. For instance, this combination has been used in immunocompromised patients with endophthalmitis, meningitis, or osteomyelitis. Flucytosine appears to interact synergistically with amphotericin B in animal models.

In August 2013, the US Food and Drug Administration (FDA) announced that clinicians should no longer prescribe ketoconazole tablets as a first-line therapy for any fungal infection, including Candida and dermatophyte infections, because of the risk for severe liver injury, adrenal insufficiency, and adverse drug interactions.The FDA also cautioned that ketoconazole tablets should not be prescribed for any patient with underlying liver disease. The labeling changes do not apply to topical formulations of ketoconazole in creams, shampoos, foams, and gels. Oral ketoconazole is now indicated only for endemic mycoses in patients who fail to respond to or cannot tolerate other treatments.

Most localized cutaneous candidiasis infections may be treated with any number of topical antifungal agents (eg, clotrimazole, econazole, ciclopirox, miconazole, ketoconazole, nystatin). If the infection is a paronychia, the most important aspect of therapy is drainage of the abscess, followed by oral antifungal therapy with either fluconazole or itraconazole. In cases of extensive cutaneous infections, infections in immunocompromised patients, folliculitis, or onychomycosis, systemic antifungal therapy is recommended.

Candidemia requires treatment in all patient populations. Current recommendations depend on the presence or absence of neutropenia. In patients without neutropenia, fluconazole is the drug of choice in most cases of candidemia and disseminated candidiasis. An echinocandin is recommended for candidemia in most patients with neutropenia. Fluconazole is an alternative in patients who are less critically ill and who have no recent azole exposure. Voriconazole can be used when additional mold coverage is desired.

For more on the treatment of candidiasis, read here.

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