Candidiasis, renal

Penicillins should be used cautiously in patients witii renal disease, pregnancy (Pregnancy Category C), lactation (may cause diarrhea or candidiasis in die infant), and in tiiose witii a history of allergies. Any indication of sensitivity is reason for caution. The drug is also used witii caution in patients witii asthma, renal disease, bleeding disorders, and gastrointestinal disease. 

Urinary candidiasis Fluconazole 200 mg IV or PO for 7-14 days OR Amphotericin B 0.3 mg/kg per day IV for 1-7 days Asymptomatic candiduria does not required therapy However, treatment is recommended in neutropenic, low-birth-weight infants, and patients undergoing urologic manipulations or those with renal allografts Amphotericin B bladder irrigation no longer recommended... 

Renal function impairment There is no need to adjust single dose therapy for vaginal candidiasis in patients with impaired renal function. In patients with impaired renal function who will receive multiple doses, give an initial loading dose of 50 to 400 mg. After the loading dose, base the daily dose on the following table ... 

Uses Severe, systemic fungal Infxns oral cutaneous candidiasis Action Binds ergosterol in the fungal membrane to alter permeability Dose Adults Peds. Test dose 1 mg IV adults or 0.1 mg/kg to 1 mg IV in children then 0.25-1.5 mg/kg/24 h IV over 2-6 h (range 25-50 mg/d or qod). Total dose varies w/ indication PO 1 mL qid Caution [B, ] Disp Inj SE -1- K /Mg from renal wasting anaphylaxis reported, HA, fever, chills, n hrotox, -1- BP, anemia, rigors Notes -1- In renal impair pre-Tx w/ APAP antihistamines (Benadryl) X SE Interactions T Nephrotoxic effects W/ antineoplastics, cyclosporine, furosemide, vancomycin, aminoglycosides, T hypokalemia W/ corticost oids, skeletal muscle relaxants EMS May cause electrolyte imbalances, monitor ECG OD May effect CV and resp Fxn symptomatic and supportive... 

Amphotericin B Cholesteryl (Amphotec) [Antifungal/Polyene Mocrollde] Uses AspCTgillosis if intolCTant/refractory to conventional amphotericin B, systemic candidiasis Action Binds ceU membrane sterols, alters permeability Dose Adults Peds. Test dose 1.6—8.3 mg, over 15-20 min, then 3-4 mg/kg/d 1 mg/kg/h inf w/ renal insuff Caution [B, ] Disp Inj SE Anaphylaxis fever, chills, HA, nephrotox, -1- BP, anemia Notes Do not use in-line filter Interactions See Amphotericin B EMS See AmphotCTicin B OD May cause cardiac arrest s ptomatic and supportive... 

Dosage Oropharyngeal Candidiasis 200 mg on first day, followed by 100 mg/d for at least 2 weeks Esophageal Candidiasis 200 mg on first day, followed by 100 mg/d for a minimum of 3 weeks and for at least 2 weeks after resolution of symptoms Systemic Candidiasis Up to 400 mg/d Cryptococcal Meningitis 400 mg on first day, followed by 200 mg/d for 10 to 12 weeks after cerebrospinal fluid becomes culture negative Dosage Adjustments lor Renal Impairment CrCl (mL/min) % of Recommended Dose >50 100% 11-50 50% Patients on hemodialysis One recommended dose after each dialysis ... 

Lipid and lysosomal amphorericn B may reduce the incidence of renal toxicity but are expensive. 2.0 mg/kg/d to 2.5 mg/kg/d IV for candidiasis have been used. 

K. M. Wasan and J. S. Conklin, Evaluation of renal toxicity and antifungal activity of free and liposomal amphotericin B following a single intravenous dose to diabetic rats with systemic candidiasis, Antimicrob. Agents Chemother. 40 1806-1810, (1996). 

Fluconazole is used for superficial mucosal candidiasis and fungal skin infections. It should be used with caution in patients with renal and hepatic dysfunction. It is reported that teratogenicity is observed in animals hence it is not recommended for use in pregnant women.66 66g Adverse effects include abdominal pain and diarrhea. Alopecia has occasionally been reported in patients during prolonged use.67... 

Shirkhoda, A. CT findings in hepatosplenic and renal candidiasis. J. Comput. Assist. Tomogr. 1987 11 795-798... 

The efficacy and tolerability of amphotericin prepared in Intralipid 20% have been evaluated in 16 patients with HIV infection and esophageal candidiasis or cryptococcosis and compared with standard amphotericin in a matched group of 24 patients (44). While both formulations had apparently similar clinical and microbiological efficacy, fewer patients receiving the lipid emulsion formulation required premedication or symptomatic therapy for infusion-associated adverse events, and fewer patients were withdrawn because of adverse effects. Renal adverse effects (a rise in serum creatinine and/or electrolyte loss) were more common in patients who received the conventional formulation. 

Serum potassium concentrations were determined at the end of a 2-hour infusion of amphotericin deoxycholate (1 mg/kg/day) in a 2-year-old girl with systemic candidiasis receiving long-term hemodialysis for renal dysplasia (85). The potassium concentration was 6.7 mmol/1, despite dialysis against a 1.5 mmol/1 potassium bath just before the infusion. The next dose was given during dialysis, and the serum potassium concentration was 2.6 mmol/1 after the infusion. 

There has been a retrospective comparison of the renal effects of ABLC with amphotericin deoxycholate in the treatment of invasive candidiasis and cryptococcosis in dosages of 0.6-5 mg/kg/day most patients received 5 mg/kg/day (115). Changes in serum creatinine were evaluated in three ways doubling of the baseline value, an increase from below 132 pmol/l (1.5 mg/dl) at baseline to over 132 pmol/l, and an increase from below 132 pmol/l at baseline to at least 177 pmol/l (2.0 mg/dl). These endpoints were achieved significantly more often with amphotericin deoxycholate than with ABLC, and the time needed to reach each of the endpoints was significantly shorter with amphotericin deoxycholate. An increased serum creatinine concentration was reported as an adverse event more often in patients receiving amphotericin deoxycholate than in patients receiving ABLC (24 versus 43%). 

The use of fluconazole in 726 children under 1 year of age, reported in 78 publications, has been reviewed (64). They received a wide range of dosages for up to 162 days. Fluconazole was well tolerated and efficacious in the therapy of systemic candidiasis and candidemia in children under 1 year of age, including neonates and very low birth-weight infants. The daily dosage recommended by the manufacturers is 6 mg/kg, to be reduced in patients with impaired renal function in accordance with the guidelines given for adults. 

B. Azole antifungals include systemic agents such as keto-conazole, fluconazole, itraconazole, and voriconazole. Topical agents used for the treatment of vaginal candidiasis and thrush include miconazole and clotrimazole. The pharmacologic properties of the systemic azoles differ considerably. Ketoconazole, the first oral azole developed, has poor bioavailability and requires an acidic environment for enhanced absorption. Thus, initial studies required ketoconazole to be administered with a cola to increase bioavailability. Fluconazole, unlike itraconazole and ketoconazole, is hydrophillic and has increased penetration across the blood-brain barrier. Fluconazole is also the only azole that is renally eliminated. 

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