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Candidiasis

Candidiasis. Candida sp. albican non-albican : C. glabrata, C . krusei, C . parapsilosis, C . tropicalis, C . parapsilosis. Candida infection. LOCAL MUCOUS MEMBRANE INFECTIONS INVASIVE FOCAL INFECTIONS CANDIDEMIA AND DISSEMINATED CANDIDIASIS. Candida sp.

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Candidiasis

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  1. Candidiasis Downloded from www.pharmacy123.blogfa.com

  2. Candida sp. • albican • non-albican: C. glabrata, C. krusei, C. parapsilosis, C. tropicalis,C. parapsilosis Downloded from www.pharmacy123.blogfa.com

  3. Candida infection • LOCAL MUCOUS MEMBRANE INFECTIONS • INVASIVE FOCAL INFECTIONS • CANDIDEMIA AND DISSEMINATED CANDIDIASIS Downloded from www.pharmacy123.blogfa.com

  4. Candidasp. • Normal flora in the gastrointestinal and genitourinary tracts of humans. Downloded from www.pharmacy123.blogfa.com

  5. Candida infection • Immune response is an important determinant of the type of infection. • Benign infections: local overgrowth on mucous membranes • More extensive persistent mucous membrane infections: deficiencies in cell-mediated immunity. • Invasive focal infections: after hematogenous spread or when anatomic abnormalities or devices Downloded from www.pharmacy123.blogfa.com

  6. LOCAL MUCOUS MEMBRANE INFECTIONS • Oropharyngeal candidiasis • Esophagitis • Vulvovaginitis • Chronic mucocutaneous candidiasis Downloded from www.pharmacy123.blogfa.com

  7. Oropharyngeal candidiasis • A common local infection. • Host: infants, older adults who wear dentures, patients treated with antibiotics, chemotherapy, or radiation therapy to the head and neck, and cellular immune deficiency states. • Symptoms: cottony feeling, loss of taste, pain on eating and swallowing, asymptomatic Downloded from www.pharmacy123.blogfa.com

  8. Oropharyngeal candidiasis • Signs: Downloded from www.pharmacy123.blogfa.com

  9. Oropharyngeal candidiasis • Diagnosis: Gram stain or KOH preparation on the scrapings. Budding yeasts with or without pseudohyphae. • Rx: • Clotrimazole troche (10 mg troche dissolved five times per day) • Nystatin suspension (400,000 to 600,000 units four times per day) • Nystatin troche (200,000 to 400,000 units four to five times per day), • For 7 to 14 days Downloded from www.pharmacy123.blogfa.com

  10. Esophagitis • AIDS-defining illness • Clinical: odynophagia or pain on swallowing • Dx: endoscopy • Confirmatory biopsy shows the presence of yeasts and pseudohyphae invading mucosal cells, and culture reveals Candida. Downloded from www.pharmacy123.blogfa.com

  11. Esophagitis • Rx: • Fluconazole 200 mg once daily then 100 mg for 14 d • Amphotericin B 0.3-0.7 mkd iv for 14 d Downloded from www.pharmacy123.blogfa.com

  12. Vulvovaginitis • Risk: associated with increased estrogen levels, antibiotics, corticosteroids, diabetes mellitus, HIV infection, intrauterine devices, and diaphragm use • Symptoms: itching and discharge. Dyspareunia, dysuria, and vaginal irritation. • Signs: vulvar erythema and swelling and vaginal erythema and discharge, which is classically white and curd-like but may be watery Downloded from www.pharmacy123.blogfa.com

  13. Vulvovaginitis • Dx: Wet mount or KOH preparation of vaginal secretions • Rx: • clotrimazole 100 mg vg suppo. for 7 d • fluconazole 150 mg oral single dose Downloded from www.pharmacy123.blogfa.com

  14. Chronic mucocutaneous candidiasis • A rare syndrome • Onset in childhood • Some have autosomal recessive polyglandular autoimmune syndrome type I, referred to as the autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) syndrome • manifested by chronic mucocutaneous candidiasis and endocrine disorders, such as hypoparathyroidism, adrenal insufficiency, and primary hypogonadism Downloded from www.pharmacy123.blogfa.com

  15. Chronic mucocutaneous candidiasis • Clinical: severe, recurrent thrush, onychomycosis, vaginitis, and chronic skin lesions (hyperkeratotic, crusted appearance on the face, scalp, and hands) • Rx: oral fluconazole,itraconazole Downloded from www.pharmacy123.blogfa.com

  16. RISK FACTORS FOR INVASIVE INFECTION • immunosuppressed patients • Hematologic malignancies • Recipients of solid organ or hematopoietic stem cell transplants • Those given chemotherapeutic agents for a variety of different diseases • intensive carepatients • Trauma and Burn patients, • Neonatal units • Central venous catheters • Total parenteral nutrition • Broad-spectrum antibiotics • High APACHE II scores • Renal failure requiring hemodialysis • Abdominal surgical procedures • Gastrointestinal tract perforations and anastomotic leaks Downloded from www.pharmacy123.blogfa.com

  17. INVASIVE FOCAL INFECTIONS • Urinary tract infection • Endophthalmitis • Osteoarticular infections • Meningitis • Endocarditis • Hepatosplenic or chronic disseminated candidiasis • Peritonitis and intraabdominal infections • Pneumonia • Mediastinitis • Pericarditis Downloded from www.pharmacy123.blogfa.com

  18. Urinary tract infection • BLADDER INFECTION AND COLONIZATION • KIDNEY INFECTION Downloded from www.pharmacy123.blogfa.com

  19. BLADDER INFECTION AND COLONIZATION • Risk factors: urinary tract drainage devices; prior antibiotic therapy; diabetes; urinary tract pathology and malignancy. • Most patients with candiduria are asymptomatic. • It is difficult to differentiate between colonization and bladder infection. • Infected patients may have dysuria, frequency, and suprapubic discomfort, no symptoms. • Pyuria with a chronic indwelling bladder catheter that it cannot be used to indicate infection. Downloded from www.pharmacy123.blogfa.com

  20. BLADDER INFECTION AND COLONIZATION • Ascending involvement of the kidneys is uncommon but can occur in urinary tract obstruction or renal transplantation. • Candiuria can be seen in systemic infection, it is accompanied by many other signs and symptoms of disseminated infection. Downloded from www.pharmacy123.blogfa.com

  21. BLADDER INFECTION AND COLONIZATION Recommendations: IDSA • Asymptomatic candiduria rarely requires antifungal therapy, if kidney transplantation, neutropenia, low birth-weight neonates, or urinary tract manipulation. • Asymptomatic candiduria may respond to risk factor reduction by removal of bladder catheters or urologic stents, and discontinuation of antibiotics ]. If it is not possible, placement of new devices or intermittent bladder catheterization may be beneficial. • Symptomatic candiduria should always be treated. • Rx: • Fluconazole 200 mg/day 7- 14 days, • Azole-resistant yeast can be treated with intravenous amphotericin B 0.3-0.7 mg/kg per day for 1-7 days Downloded from www.pharmacy123.blogfa.com

  22. KIDNEY INFECTION • Most commonly occurs in patients with disseminated • Acute infection • Bilateral, consisting of multiple microabscesses in the cortex and medulla • Chronic infection • Involve the renal pelvis and medulla with sparing of the cortex, which reflects ascending infection. • The kidney is usually the only organ involved and the infection tends to be unilateral Downloded from www.pharmacy123.blogfa.com

  23. KIDNEY INFECTION • Rx: • Amphotericin B (0.5 to 1.0 mg/kg/day) • Fluconazole (400 mg/day adjusted for renal function). • At least 2 weeks • removal and replacement of all intravenous catheters Downloded from www.pharmacy123.blogfa.com

  24. Endocarditis • Risk: prosthetic heart valves, IVDU, indwelling central venous catheters and prolonged fungemia. • Dx: Duke criteria • Rx: • Amphotericin B 0.7-1 MKD at least 6 weeks. with fluconazole being substituted for amphotericin B as follow-up therapy. • Resection of the valve and any associated abscesses Downloded from www.pharmacy123.blogfa.com

  25. CANDIDEMIA AND DISSEMINATED CANDIDIASIS • Candidiemia: presence of Candida sp. in the blood • Disseminated candidiasis: several viscera are infected Downloded from www.pharmacy123.blogfa.com

  26. PATHOGENESIS • three major routes by which Candida gain access to the bloodstream: • Through the gastrointestinal tract mucosal barrier • Via an intravascular catheter • From a localized focus of infection, such as pyelonephritis Downloded from www.pharmacy123.blogfa.com

  27. CLINICAL MANIFESTATIONS • Vary from minimal fever to a full-blown sepsis syndrome • Clinical clues: • characteristic eye lesions (chorioretinitis, endophthalmitis), • skin lesions, • much less commonly, muscle abscesses. • signs of multiorgan system failure may present: kidneys, heart, liver, spleen, lungs, eyes, and brain Downloded from www.pharmacy123.blogfa.com

  28. CLINICAL MANIFESTATIONS • Skin lesions: • Suddenly as clusters of painless pustules on an erythematous base; occur on any area of the body. • The lesions vary from tiny pustules or nodular; several centimeters in diameter; and appear necrotic in the center. • In severely neutropenic patients, the lesions may be macular rather than pustular. • Dx: by a punch biopsy. Downloded from www.pharmacy123.blogfa.com

  29. CLINICAL MANIFESTATIONS • Skin lesions Downloded from www.pharmacy123.blogfa.com

  30. CLINICAL MANIFESTATIONS • Eye lesions: • Exogenous: following trauma or surgery on the eye • Endogenous: through hematogenous seeding of the retina and choroid as a complication of candidemia. • Primary presenting symptoms: pain and gradual decrease in visual acuity. • The classic findings of chorioretinal involvement: focal, glistening, white, infiltrative, often mound-like lesions on the retina, a vitreal haze is present; sometimes fluffy white balls or "snowballs" in the vitreous Downloded from www.pharmacy123.blogfa.com

  31. CLINICAL MANIFESTATIONS • Eye lesions Downloded from www.pharmacy123.blogfa.com

  32. CLINICAL MANIFESTATIONS • Muscle abcess • soreness in a discrete muscle group. • warm and swollen Downloded from www.pharmacy123.blogfa.com

  33. DIAGNOSIS • Gold standard: candidemia is a positive blood culture • Blood cultures: H/C +ve 50 % of patients who were found to have disseminated candidiasis at autopsy. • Ophthalmologic evaluation: Once H/C+ve, whether or not they have ocular symptoms • Culture and stain of biopsy material Downloded from www.pharmacy123.blogfa.com

  34. Treatment • CATHETER REMOVAL • ANTIFUNGAL AGENTS • Polyenes: Amphotericin B • Azoles: Fluconazole, Itraconazole and Voriconazole. • Echinocandins:Caspofungin Downloded from www.pharmacy123.blogfa.com

  35. DRUG RESISTANCE • C. albicans; resistance is extremely low • C. krusei; intrinsically resistant to fluconazole due to an altered cytochrome P-450 isoenzyme, sometimes demonstrates decreased susceptibility to amphotericin B • susceptible to voriconazole • increased doses of amphotericin B Downloded from www.pharmacy123.blogfa.com

  36. DRUG RESISTANCE • C. glabrata; many are also resistant to the azoles due to changes in drug efflux, Amphotericin B also has delayed killing kinetics against C. glabrata in vitro • using high doses of fluconazole, amphotericin B Downloded from www.pharmacy123.blogfa.com

  37. DRUG RESISTANCE • C. parapsilosis ; • very susceptible to most antifungal agents; • caspofungin minimal inhibitory concentrations are higher than for other Candida species Downloded from www.pharmacy123.blogfa.com

  38. DRUG RESISTANCE • C. lusitaniae • often resistant to amphotericin therapy; • usually susceptible to azoles and echinocandins Downloded from www.pharmacy123.blogfa.com

  39. Treatment • Fluconazole 400 mg or 800 mg of daily • Amphotericin B 0.7 mg/kg per day • Caspofungin is 50 mg/day after a loading dose of 70 mg • Voriconazole is 3 mg/kg twice daily after a loading dose of 6 mg/kg twice daily for one day. • C. glabrata and C. krusei, higher doses of amphotericin B (1 mg/kg daily of standard amphotericin B • Duration of therapy for candidemia : • A minimum of two weeks of therapy after blood cultures become negative Downloded from www.pharmacy123.blogfa.com

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