Infectious Diseases II

Empiric treatment of critically ill patients: A recent large, multicenter study evaluated the use of empiric

micafungin in immunocompromised critically ill patients with sepsis, multiple Candida colonization,

multiorgan failure, and exposure to broad-spectrum antibiotics. The study showed no improvement

in fungal infection-free survival compared with placebo. Until further evidence is available, empiric

echinocandins should not be administered routinely.

Mechanism of action: Converted by fungal enzymes to fluorouracil, which disrupts fungal RNA and

DNA synthesis

Candida spp.

Cryptococcus: Treatment of choice (in conjunction with amphotericin) for Cryptococcus meningitis

Dose

25 mg/kg every 6 hours

Renal adjustments necessary

Well absorbed: Bioavailability 80%–90%

Therapeutic drug monitoring may be necessary. Please see the Pharmacokinetics/

Pharmacodynamics chapter for further discussion.

Adverse reactions: Bone marrow suppression, particularly with supratherapeutic concentrations

Patient Case

A 66-year-old woman (height 66 inches, weight 75 kg) is admitted to the medical ICU for dehydration and

acute kidney injury. The patient recently received an allogeneic bone marrow transplant and has not yet

engrafted. She has been pancytopenic for 12 days. On day 5 of the medical ICU stay, the patient develops

acute respiratory distress requiring intubation. Bronchoalveolar lavage is done, which eventually grows

Aspergillus fumigatus, and the patient is given a diagnosis of invasive pulmonary aspergillosis. The patient’s

current medications include tacrolimus, corticosteroids, and fluconazole fungal prophylaxis. Her current

relevant laboratory values are as follows: WBC 0.2 x 103 cells/mm3, lactate 1.5 mmol/L, and SCr 3.4 mg/dL.

Which antifungal therapy is most appropriate?

Healthcare access and quality

Neighborhood and built environment

Education access and quality

Community and social context