Fluconazole candidiasis

Treat nipple candidiasis by applying topical ketoconazole, nystatin, or miconazole to the nipples after each feeding and by administering oral nystatin drops to the breast-feeding infant12 (Table 44-5). In severe or recurrent cases, the mother may be treated with oral fluconazole.12,14 Although messy, gentian violet applied topically to both the nipples and the infant s mouth is also effective for resistant cases.12... 

Two to three weeks of fluconazole or itraconazole solution are highly effective and demonstrate similar clinical response rates.32 Doses of 100 to 200 mg are effective in immunocompetent patients but doses up to 400 mg are recommended for immunocompromised patients. Due to variable absorption, ketoconazole and itraconazole capsules should be considered second-line therapy. In severe cases, oral azoles may prove ineffective, warranting the use of amphotericin B for 10 days. Although echinocandins and voriconazole are effective in treatment of esophageal candidiasis, experience remains limited. 

Twenty percent of HIV-infected patients develop fluconazole-resistant Candida albicans isolates after repeated exposure to fluconazole.33 To treat fluconazole-resistant oropharyngeal candidiasis, daily itraconazole for 2 to 4 weeks may be used. Oral itraconazole solution exhibits a mycological cure rate of 88% and a clinical cure rate of 97% in immunocompromised patients.34 Fluconazole-resistant esophageal candidiasis should be treated with intravenous amphotericin B or caspofungin. 

If immunocompromised patients experience frequent or severe recurrences, particularly of esophageal candidiasis, chronic maintenance therapy with fluconazole 100 to 200 mg daily should be considered. In patients with infrequent or mild cases, secondary prophylaxis is not recommended. The rationale for not giving prophylaxis includes availability of effective treatments for acute episodes, risk of developing resistant organisms, potential for drug interactions, and the cost of therapy. 

If a patient is non-neutropenic and has never received prior azole therapy, fluconazole 800 mg/day is an appropriate first-line therapy for invasive candidiasis until identification of the Candida isolate. Amphotericin B deoxycholate 0.7 mg/kg per day or caspofungin 70 mg on day 1, then 50 mg/day, voriconazole, or a lipid amphotericin B formulation are recommended as empiric therapy in patients with neutropenic fever. 

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... 

Mucocutaneous candidiasis is generally not life-threatening nor invasive and can be treated with topical azoles (clotrimazole troches), oral azoles (fluconazole, ketoconazole, or itraconazole), or oral polyenes (such as nystatin or oral amphotericin B). Orally administered and absorbed azoles (ketoconazole, fluconazole, or itraconazole solution), amphotericin B suspension, intravenous caspofungin, or intravenous amphotericin B are recommended for refractory or recurrent infections.20... 

Although more invasive, esophageal candidiasis does not typically evolve into a life-threatening infection. However, topical therapy is ineffective. Azoles (fluconazole, itraconazole solution, or voriconazole), echinocandins, or intravenous amphotericin B (in cases of unresponsive infections) are effective treatment options. Parenteral therapy should be used in patients who are unable to take oral medications.20... 

Response to antifungal therapy in invasive candidiasis is often more rapid than for endemic fungal infections. Resolution of fever and sterilization of blood cultures are indications of response to antifungal therapy. Toxicity associated with antifungal therapy is similar in these patients as described earlier with the caveat that some toxicities maybe more pronounced in crit-ically-ill patients with invasive candidiasis. Nephrotoxicity and electrolyte disturbances, with amphotericin B in particular, are problematic and may not be avoidable even with lipid amphotericin B formulations. Fluconazole and echinocandins are generally safer options, and are generally well tolerated. Decisions to use one class of agents over the other is principally driven by concerns of non-albicans species, patient tolerability, or history of prior fluconazole exposure (risk factor for non-albicans species.). 

Fluconazole (400 mg/day) has been extensively studied as a prophylactic regimen to prevent invasive candidiasis in patients... 

Treatment of candidiasis is presented in Table 38-4. Amphotericin B may be switched to fluconazole (IV or oral) for completion of therapy. Azoles and deoxycholate amphotericin B are similarly effective however, fewer adverse effects are observed with azoles. Echinocandins are at least as effective as amphotericin B or fluconazole in nonneutropenic adult patients with candidemia. 

Lipid formulation of amphotericin B IV 3-5 m kg/day Chronic disseminated candidiasis Treatment duration Until calcification or resolution of lesions (hepatosplenic candidiasis) stable patients Fluconazole IV/po 6 mg/kg/day... 

Fluconazole is a triazole antifungal that may be administered in recurrent vaginal candidiasis. Fluconazole interacts with sulphonylureas such as glibenclamide, resulting in increased plasma concentrations of the sulphonylurea. 

Prevention of candidiasis in bone marrow transplant 400 mg once daily. In patients who are anticipated to have severe granulocytopenia (less than 500 neutrophils/mm ), start fluconazole prophylaxis several days before the anticipated onset of neutropenia, and continue for 7 days after the neutrophil count rises above 1000 cells/mm. ... 

Oropharyngeal candidiasis - 200 mg/day for 1 to 2 weeks. Vigorously swish the solution in the mouth (10 ml at a time) for several seconds and swallow. For patients with oropharyngeal candidiasis unresponsive/refractory to treatment with fluconazole tablets, the recommended dose of itraconazole is 100 mg twice daily. Expect clinical response in 2 to 4 weeks. Patients may be expected to relapse shortly after discontinuing therapy. Limited data on the safety of long-term use (more than 6 months) of the oral solution are available at this time. 

Fluconazole is very effective in the treatment of infections with most Candida spp. Thrush in the end-stage AIDS patient, often refractory to nystatin, clotrimazole, and ketoconazole, can usually be suppressed with oral fluconazole. AIDS patients with esophageal candidiasis also usually respond to fluconazole. A single 150-mg dose has been shown to be effective treatment for vaginal candidiasis. A 3-day course of oral fluconazole is effective treatment for Candida urinary tract infection and is more convenient than amphotericin B bladder irrigation. Preliminary findings suggest that Candida endophthalmitis can be successfully treated with fluconazole. Stable nonneutropenic patients with candidemia can be adequately treated with fluconazole, but unstable, immunosuppressed patients should initially receive... 

A significant decrease in mortality from deep-seated mycoses was noted among bone marrow transplant recipients treated prophylactically with fluconazole, but similar benefits have not been seen in leukemia patients receiving prophylactic fluconazole. Fluconazole taken prophylactically by end-stage AIDS patients can reduce the incidence of cryptococcal meningitis, esophageal candidiasis, and superficial fungal infections. 

Ketoconazole remains useful in the treatment of cutaneous and mucous membrane dermatophyte and yeast infections, but it has been replaced by the newer triazoles in the treatment of most serious Candida infections and disseminated mycoses. Ketoconazole is usually effective in the treatment of thrush, but fluconazole is superior to ketoconazole for refractory thrush. Widespread dermatophyte infections on skin surfaces can be treated easily with oral ketoconazole when the use of topical antifungal agents would be impractical. Treatment of vulvovaginal candidiasis with topical imidazoles is less expensive. 

Fluconazole is well absorbed following oral administration, with a plasma half-life of 30 hours. In view of this long half-life, daily doses of 100 mg are sufficient to treat mucocutaneous candidiasis alternate-day doses are sufficient for dermatophyte infections. The plasma half-life of itraconazole is similar to that of fluconazole, and detectable therapeutic concentrations remain in the stratum corneum for up to 28 days following termination of therapy. Itraconazole is effective for the treatment of onychomycosis in a dosage of 200 mg daily taken with food to ensure maximum absorption for 3 consecutive months. Recent reports of heart failure in patients receiving itraconazole for onychomycosis have resulted in recommendations that it not be given for treatment of onychomycosis in patients with ventricular dysfunction. 

Fluconazole 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... 

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