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Fungal infections
Yeast
Candida
Candida : - Candida albicans
- Candida non-albicans
C.glabrata, C.krusei, C.parapsilosis
Cryptococcus neoformans var neoformans
Pneumocystis jirovecii
Filamentous fungi or moulds
Aspergillus sp
Scedosporium apiospermum and S. proliferans
Zygomycetes (Mucor, Rhizopus, Rhizomucor)
Fusarium
Molds:
- Histo/cytochemistry showing hypae or
spherules with evidence of associated tissue
damage, either microscopically or radiologically
OR
- (+) culture from infection site
Yeasts :
Fungemia
Molds:
AND
1 microbiological OR 1 major (or 2
minor) clinical criteria from an abnormal
site consistent with infection
Host Factors
1.
2.
3.
4.
5.
2.
3.
4.
5.
Clinical Criteria
Should be related to the site of
microbiological criteria and temporally
related to the current episode
Sinonasal Infection
Major
Sinonasal Infection
1.
2.
3.
4.
5.
Minor
Upper respiratory symptoms (nasal
discharge, stuffiness etc)
Nose ulceration/eschar of nasal
mucosa/epitaxis
Periorbital swelling
Maxillary tenderness
Black necrotic lesions/perforation of the
hard palate
1.
2.
3.
4.
Minor
Focal neurologic symptoms and signs
(including focal seizures, hemiparesis and
cranial nerve palsies)
Mental changes
Meningeal irritation findings
Abnormalities in DSF biochemistry and cell
count
Possible Candidemia
No prominent signs or symptoms of
Intermediate : high
High
Organ/system
Features
Likely infection
Skin
Acute disseminated
candidosis,
disseminated
aspergillosis or
Fusarium infection
Sinus
Palate
Ulceration, including
the hard palate
Thinocerebral
mucormycosis
Organ/system
Features
Likely infection
Chest
Invasive pulmonary
aspergillosis, PCP,or
other fungal pneumonia
Eyes
Funduscopy may
Acute disseminated
reveal cotton-wool ball candidosis
lesions of Candida
Choroidoretinitis-rare in
neutropenic patients
Central nervous
system
Headache, altered
mental state, seizure,
focal neurologic signs,
and neck stiffness
Cryptococcal or
candidal meningitis
Aspergilosis
Microscopy of sputum, BAL fluid (enhanced by
Candidosis
Microscopy of body fluids (enhanced by Calcofluor
Cryptococcosis
Microscopy of CSF or other body fluids and
secretions
Culture of CSF, blood, sputum, urine and prostatic
fluid
Detection of antigen in CSF, urine and blood by
latex agglutination
(e.g Immuno-Mycologics Inc; Meridian
Diagnostics Inc; Bio-Rad) and ELISA (Meridian
Diagnostics Inc)
Histoplasmosis
Microscopy of stained smears of peripheral
Disease probability
No treatment
Treatment
Depends on
1. Feasibility and predictive values of
diagnostic tests
2. Efficacy of treatment
3. Cost
4. Potential adverse effects of treatment
5. Impacts of no treatment or delay in
treatment
2.
3.
4.
Prophylaxis therapy
Antifungal therapy is given based on patients risk factors,
no signs of infection (predictive value > 75%)
Pre-emptive therapy (targeted prophylaxis): Antifungal
therapy is given based on patients risk factors, and
fungal colony is found (or neutropenia), no sign of
infection (predictive value > 75%)
Empiric therapy
Antifungal therapy is given based on patients risk factors,
sign of infection are present but the etiology is not clear
Definitive therapy
Infection signs are present, fungal infectiuon diagnosis is
proven by histopathology examination (fungemia),
specificity > 95%
Prophylaxis Empirical
Preemptive
Targeted
Yes
Yes
Low
Intermediate
low; not colonized,
HEPA filtered
high; colonized
Yes
?
Yes
Yes
Not relevant
Yes
Yes
High
Yes
Yes
Not relevant
Yes
Systemic Antifungal
Polyenes
Amphotericin B deoxycholate
Liposomal amphotericin B
Amphotericin B colloidal dispersion
(ABCD)
Amphotericin B lipid complex (ABLC)
Systemic Antifungals
Azole
Imidazole
Ketokonazole
Triazole
Flucinazole
Itraconazole
2nd generation Triazole
Voriconazole (fluconazole congener)
Ravuconazple (fluconazole congener)
Posaconazole (itraconazole congener)
Candin
Candida sp
C. Albicans
C. tropicalis
C.Parapsilosis
C.Glabrata
C.Krusei
C.Lusitaniae
S: sensitive
S
S
S
SDD-R
R
S
S
S
S
SDD-R
SDD-R
S
I: intermediate
R: resisten
S
S
S
S-I
S-I
S
S
S
S
S
I-R
S
S
S
S
S-I
S-I
S-R
Fluconazole
Spectrum activity to Candida sp and
Cryptococcus neoformans
Indication: mucocutaneous candidiasis,
Candidemia, Crytococcal meningitis (alternative
drugs/maintenance)
Good bioavaiability (90% oral absorbtion) not
affected by food
Elimination in kidney
High level in CSF (80%)
Potential interaction with phenytoin, glipizide,
glyburide, tolbutamide, warfarin, rifabutin or
cyclosporine
Side effect : increased ALT and AST
Voriconazole
Indication : invasive aspergillosis, other
Itraconazole
Indication: oral and esophangeal candidiasis,
Kasus
Seorang Pria 81 th dg riwayat DM, CVD lama
- tracheostomi
- CVC
- NGT
- Kateter urin
Terapi diberikan:
Cefepime + moxifloxacin
Nutrisi parenteral parsial
Dilakukan tindakan bronkoskopi untuk
membersihkan brionkus: didapatkan
gambaran bronkus hiperemis
Dilakukan kultur bilasan bronkus
Pada foto thoraks ulang didapatkan kesan
perburukan
Keadaan klinis stabil demam masih belum
turun
R
R
I(15)
I(19)
S(25)
R
R
R
R
R
I(20)
Cefepime
Amikacin
Dibekacin
Imipenem
Meropenem
Ciprofloxacin
Moxifloxacin
Levofloxacin
Cotrimoxazol
Fosfomycin
R
S (18)
R
S(25)
S(25)
R
R
R
R
S(21)
Pertanyaan 1
Candida albicans yang didapatkan
1.
2.
3.
4.
5.
Pertanyaan 2
Faktor resiko infeksi jamur sistemik
1.
2.
3.
4.
5.
Pertanyaan 3
Terapi antifungal yang akan diberikan:
1. Fluconazole 1x150 mg tab
2. Fluconazole 1x200 mg iv
3. Itraconazole 2x100 mg tab
4. Voriconazole 2x200 mg iv
5. Amfotericin B 0.7 mg/kgBB/hr
Pertanyaan 4
Terapi antifungal yang diberikan
1.
2.
3.
4.
merupakan terapi
Profilaksis
Pre-emptive
Empirik
Definitive
Pertanyaan 5
Lama pemberian antifungal:
1. 5 hari
2. 7 hari
3. 14 hari
4. 3 minggu
5. 6 bulan
DISKUSI
Imipenem 4 x 500 mg iv
Fluconazole 1 x 200 mg iv
selama 14 hari
pleura : eksudat
sel B limposit 90%
BTA negatif
Diberikan terpi empirik OAT
Acinobacter baumanii
Candida lipolytica
Pertanyaan 6
Candida yang terdapat pada pasien
1.
2.
3.
4.
ini merupakan
Kontaminasi
Kolonisasi
Infeksi jamur invasif
Infeksi jamur sistemik
Pertanyaan 7
Terapi antifungal yang diberikan
1.
2.
3.
4.
merupakan terapi
Profilaksis
Pre-emptive
Empirik
Definit
Pertanyaan 8
Terapi antifungal yang akan diberikan:
1. Fluconazole 1x200 mg iv
2. Fluconazole 2x200 mg iv
3. Fluconazole 2x400 mg iv
4. Voriconazole 2x200 mg iv
5. Amfotericin B 0.7 mg/kgBB/hr
Pertanyaan 8
Tindakan yang perlu dilakukan pada
1.
2.
3.
4.
5.
pasien ini:
Ganti CVC
CT scan abdomen
Echocardiografi
Kultur darah ulang
Resistensi candida
Pertanyaan 9
Lama pemberian antifungal:
1. 7 hari
2. 14 hari
3. 1 bulan
4. Sampai kultur darah negatif
dilanjutkan 14 hari
5. 6 bulan