Sandbox carlos: Difference between revisions

Jump to navigation Jump to search
No edit summary
No edit summary
Line 33: Line 33:


:* 3. '''Special considerations for HIV/AIDS patients'''
:* 3. '''Special considerations for HIV/AIDS patients'''
::* 3.1 '''Focal Pneumonia'''
::* 3.1 '''Clinically mild infections (e.g., focal pneumonia)'''
:::* 3.1.1 Preferred regimen in mild Infections: [[Fluconazole]] 400 mg PO daily {{or}} [[Itraconazole]] 200 mg PO bid
:::* Preferred regimen: [[Fluconazole]] 400 mg PO daily {{or}} [[Itraconazole]] 200 mg PO bid
:::* 3.1.2 Alternative regimen in mild infections for patients who failed to respond to [[Fluconazole]] {{or}} [[Itraconazole]]: [[Posaconazole]] 200 mg PO bid {{or}} [[Voriconazole]] 200 mg PO bid
:::* Alternative regimen (unresponsive to Fluconazole or Itraconazole): [[Posaconazole]] 200 mg PO bid {{or}} [[Voriconazole]] 200 mg PO bid
:::* Note: Itraconazole, posaconazole, and voriconazole may have significant interactions with certain antiretro viral agents. These interactions are complex and can be bi-directional
:::* Note: Itraconazole, posaconazole, and voriconazole may have significant interactions with certain antiretro viral agents. These interactions are complex and can be bi-directional
::* 3.2 '''Severe, Non-Meningeal Infection'''
::* 3.2 '''Severe, Non-Meningeal Infection'''

Revision as of 20:42, 22 July 2015

  • 1. Primary pulmonary infection
  • 1.1 Indications for antifungal therapy
  • Immunosupression (AIDS, therapy with high dose corticosteroids, receiptients of TNF-alpha, receiptients of an organ transplant)
  • Diabetes
  • Preexisting cardiomyopathy
  • Pregnancy (third trimester)
  • Filipino or African
  • Weight loss of > 10%
  • Intense night sweats persisting longer than 3 weeks
  • Infiltrates involving more than one-half of one lung or portions of both lungs
  • Prominent or persistent hilar adenopathy
  • Anticoccidiodial complement-fixing antibody concentrations in excess of 1:16
  • 1.2 Patients with low risk of complications or dissemination
  • For many (if not most) patients, management may rely on periodic reassessment of symptoms and radiographic findings to assure resolution without antifungal treatment.
  • 1.3 Patients with high risk of complications or dissemination
  • 1.3.1 Mild to moderate pneumonia
  • Preferred regimen (1): Itraconazole solution 200 mg PO bid or IV q12h
  • Preferred regimen (2): Fluconazole 400 mg PO q24h for 3–12 months
  • 1.3.2 Locally severe or disseminated pneumonia
  • Preferred regimen: (Amphotericin B 0.6–1 mg/kg PO qd every 7 days THEN 0.8 mg/kg PO every other day OR Liposomal Amphotericin B 3-5 mg/kg IV q24 hrs OR Amphotericin B lipid complex 5 mg/kg IV q24 hrs until clinical improvement) followed by Itraconazole OR Fluconazole for at least 1 year.
  • Note (1): Some use combination of Amphotericin B and Fluconazole for progressive severe disease; controlled series lacking.
  • Note (2): Consultation with specialist recommendation, surgery may be required.
  • 2. Meningitis
  • 2.1 Adult
  • 2.2 Child
  • Preferred regimen: Fluconazole PO (Pediatric dose not established, 6 mg per kg q24h used)
  • Alternative regimen: Amphotericin B 3-5 mg/kg IV q24 hrs PLUS 0.1–0.3 mg daily intrathecal (intraventricular) via reservoir device OR itra 400–800 mg q24h OR Voriconazole
  • 3. Special considerations for HIV/AIDS patients
  • 3.1 Clinically mild infections (e.g., focal pneumonia)
  • Preferred regimen: Fluconazole 400 mg PO daily OR Itraconazole 200 mg PO bid
  • Alternative regimen (unresponsive to Fluconazole or Itraconazole): Posaconazole 200 mg PO bid OR Voriconazole 200 mg PO bid
  • Note: Itraconazole, posaconazole, and voriconazole may have significant interactions with certain antiretro viral agents. These interactions are complex and can be bi-directional
  • 3.2 Severe, Non-Meningeal Infection
  • 3.2.1 Preferred regimen in severe, Non-Meningeal Infection (Diffuse pulmonary infection or severely ill patients with extrathoracic, disseminated disease): Amphotericin B deoxycholate 0.7–1.0 mg/kg IV q12hrs OR Lipid formulation Amphotericin B 4–6 mg/kg IV q24hrs. Duration of therapy: continue until clinical improvement, then switch to an azole.
  • 3.2.2 Alternative regimen in severe, Non-Meningeal Infection (Diffuse pulmonary infection or severely ill Patients with extrathoracic, disseminated disease): Some specialists will add a triazole (Fluconazole or Itraconazole, with Itraconazole (preferred for bone disease) 400 mg per day to Amphotericin B therapy and continue triazole once Amphotericin B is stopped
  • Note (1): Therapeutic drug monitoring and dosage adjustment may be necessary to ensure triazole antifungal and antiretroviral efficacy and reduce concentration-related toxicities.
  • Note (2): Therapy should be continued indefinitely in patients with diffuse pulmonary or disseminated diseases because relapse can occur in 25%–33% of HIV-negative patients. It can also occur in HIV-infected patients with CD4 counts >250 cells/μL
  • 3.3 Meningeal Infections
  • Preferred regimen: Fluconazole 400–800 mg IV or PO daily
  • Alternative regimen: Itraconazole 200 mg PO tid for 3 days THEN 200 mg PO bid OR Posaconazole 200 mg PO bid OR Voriconazole 200–400 mg PO bid OR Intrathecal Amphotericin B deoxycholate when triazole antifungals are ineffective.
  • Note (1): Intrathecal amphotericin B should only be given in consultation with a specialist and administered by an individual with experience with the technique.
  • Note (2): Some patients with meningitis may develop hydrocephalus and require CSF shunting
  • Note (3): Therapy should be lifelong in patients with meningeal infections because relapse occurs in 80% of HIV-infected patients after discontinuation of triazole therapy
  • 3.4 Chronic Suppressive Therapy
  • Preferred regimen: Fluconazole 400 mg PO daily (AII), or Itraconazole 200 mg PO BID
  • Alternative regimen: Posaconazole 200 mg PO BID or Voriconazole 200 mg PO BID




References