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Chapter 27. Fungal Infections

Jason M. Cota; Reed C. Hall

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    AMA Citation
    Cota JM, Hall RC. Cota J.M., Hall R.C. Cota, Jason M., and Reed C. Hall.Chapter 27. Fungal Infections. In: Attridge RL, Miller ML, Moote R, Ryan L. Attridge R.L., Miller M.L., Moote R, Ryan L Eds. Rebecca L. Attridge, et al.eds. Internal Medicine: A Guide to Clinical Therapeutics New York, NY: McGraw-Hill; 2013. http://accesspharmacy.mhmedical.com/content.aspx?bookid=565&sectionid=42003741. Accessed June 21, 2018.
    MLA Citation
    Cota JM, Hall RC. Cota J.M., Hall R.C. Cota, Jason M., and Reed C. Hall.. "Chapter 27. Fungal Infections." Internal Medicine: A Guide to Clinical Therapeutics Attridge RL, Miller ML, Moote R, Ryan L. Attridge R.L., Miller M.L., Moote R, Ryan L Eds. Rebecca L. Attridge, et al. New York, NY: McGraw-Hill, 2013, http://accesspharmacy.mhmedical.com/content.aspx?bookid=565&sectionid=42003741.

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Figure 27-1.
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Classification of fungi & pathophysiology of disease.

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Table 27-1 Antifungal Drug Susceptibility Rates Against Common Fungal Pathogens (Clin Infect Dis 2009;48:503; J Clin Microbiol 2010;48:3251)
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Table 27-1 Antifungal Drug Susceptibility Rates Against Common Fungal Pathogens (Clin Infect Dis 2009;48:503; J Clin Microbiol 2010;48:3251)

Fungal Pathogen

Fluconazole

Itraconazole

Voriconazole

Posaconazole

Echinocandins

Amphotericin B

Candida spp. (% of occurrence)

C. albicans (50–60%)

+++

+++

+++

+++

+++

+++

C. glabrata (10–20%)

+

-

++

++

+++

+++

C. tropicalis (6–10%)

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+

+++

+++

+++

+++

C. parapsilosis (6–10%)

+++

+

+++

+++

++

+++

C. krusei (2–3%)

-

-

+++

+++

+++

+++

Aspergillus spp. (% of occurrence)

A. fumigates (75–80%)

-

+++

+++

+++

+++

+++

A. flavus (10–12%)

-

+++

+++

+++

+++

+++

A. niger (6–8%)

-

+++

+++

+++

+++

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A. terreus (4–6%)

-

+++

+++

+++

+++

-

+ + +, >95% susceptible; ++, 75–95% susceptible; +, 50–75% susceptible; −, negligible activity.

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Dermatophytoses

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Diagnosis & Evaluation

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  • Visualize hyphae after 1 drop of 10–20% KOH added to active lesion border scraping; higher sensitivity (76.5%) & negative predictive value (81.6%) vs culture

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Treatment & Follow-Up

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  • Tinea capitis: terbinafine 250mg PO daily × 4wk; adjunctive selenium sulfide 2.5% shampoo 2–3×/wk to ↓ spread
  • Tinea corporis, tinea cruris, tinea pedis: combination antifungal/corticosteroid preparations not recommended due to ↑ cost, ↑ risk for adverse effects, & ↓ response rates
  • Tinea unguium (onychomycosis): may withhold treatment for asymptomatic individuals with minimal nail involvement; treat associated tinea pedis in all patients; draw LFTs at baseline & at 4–6wk for terbinafine; for fingernails → terbinafine 250mg PO QD × 6wk (clinical cure rate ∼50%); for toenails →  terbinafine 250mg PO QD × 12wk (clinical cure rate ∼50%) (BMJ 1999; 318:1031); allows 48–72wk for nail growth & to assess clinical cure; in patients with contraindications to systemic therapy (active or chronic liver disease) or minimal distal dermatophyte infection → ciclopirox 8% nail lacquer daily × 48wk + podiatric debridement (mycological cure rate ∼30%; clinical cure rate <10%) (J Am Acad Dermatol 2004;50:151)

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Clinical Pearl 27-1

Topical terbinafine therapy can be applied once daily for 7d for tinea corporis, tinea cruris, & tinea pedis. All other products must be applied for 2–4wk.

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Clinical Pearl 27-2

Clinical cure rates ∼25% in patients >65yo (Am J Geriatr Pharmacother 2006;4:1).

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Table 27-2 Topical Antifungal Agents for the Treatment of Tinea Corporis, Tinea Cruris, & Tinea Pedis
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Table 27-2 Topical Antifungal Agents for the Treatment of Tinea Corporis, Tinea Cruris, & Tinea Pedis

Drug Name

Availability

Dosing

OTC?

Generic?

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