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    Antifungal Drugs Antifungal Drugs Presentation Transcript

    • Antifungal Drugs Group 7 Sison, Josef F. Songco, Marjorie Ann R. Tagupa, Gerald Bong G. Tamayo, Rose May Taotao, Krisha Anne C. Tulagan, Precious
    • Antifungal Drugs
      • Also called antimycotic drugs
      • Used to treat two types of fungal infection:
        • Superficial fungal infections
          • (skin or mucous membrane)
        • Systemic fungal infectons
          • (lungs or central nervous system)
    • Antifungal Drugs
      • Groups:
        • Polyenes ,including amphotericin B and nystatin
        • Imidazoles , which include ketoconazole, miconazole, clotrimazole and others
        • The antimetabolic antifungal flucytosine
        • Antiprotozoal agents
    • Polyenes
      • Amphotericin B
      • Nystatin (Mycostatin)
    • Amphotericin B
      • Available Forms:
        • Lozenges: 10mg
        • Oral Suspension: 100mg/mL
        • Powder for injection: 50mg
        • Tablets: 100mg
    • Amphotericin B
      • Route and Test dose:
        • A: IV: 0.25-1.0 mg in 20ml of D5W infused over 20-30 min
        • A: IV: 0.25-1.0 mg/kg/d in D5W or 1.5 mg/kg q.o.d .; max: 1.5 mg/kg/d
        • C: IV: Same as adults, expect dilution and infuse time differ
    • Amphotericin B
      • Uses:
        • For treatment of a variety of systemic fungal (mycotic) infections, such as aspergillosis, blastomycosis, coccidioidomycosis. Nephrotoxicity may occur when given in high doses. Hypokalemia might occur.
      • Consideration:
        • Pregnancy category: B; PB: 95%; t 1/2 : 24 h
    • Amphotericin B
      • Indications:
        • Systemic fungal inferctions (hystoplasmosis,coccidioidomycosis,blastomycosis,cryptococcosis,disseminated candidiasis,aspergillosis,phycomycosis,zygomycosis), meningitis
        • Infection of the G.I tract caused by Candida albicans
        • Oral and perioral candidal infections
    • Amphotericin B
      • Contraindications:
        • Contraindicated in patients hypersensitive to drug
    • Amphotericin B
      • Side Effects:
        • CNS: headache, peripheral neuropathy, transcient vertigo, malaise, seizures
        • CV: hypotension, arrhytmias, asystole, hypertension, tachycardia, flushing, phlebitis, thrombophlebitis
    • Amphotericin B
      • Side Effects:
        • EENT: hearing loss, innitus, blurred vision, diplopia
        • GI: anorexia, nausea, vomiting, dyspepsia, diarrhea, epigastric pain, crumping, melena, steatorrhea, hemorrhagic gastroenteritis
    • Amphotericin B
      • Side Effects:
        • GU: abnormal renal function with hypokalemia, azotemia hypostenuria, renal tubular acidosis, nephrocalcinosis, permanent renal impairment; anuria; oliguria
        • HEMATOLOGIC: normochronic anemia, normocytic anemia, thrombocytopenia, leukopenia, agrunulocytes, eosinophilia, leukocytosis
    • Amphotericin B
      • Side Effects:
        • HEPATIC: hepatitis, undice, acute liver failure
        • METABOLIC : weight loss, hypokalemia, hypoglycaemia, hyperglycemia, hyperuricemia, hypomagnesemia
    • Amphotericin B
      • Side Effects:
        • MUSCULOSKELETAL: arthalgia,myalgia
        • RESPIRATORY :dyspnea,tachypnea,bronchospasm,wheezing
        • SKIN : maculopopular rash,pruritus
    • Amphotericin B
      • Nursing Resposibilities:
        • Use cautiously in patients with impaired renal function
        • Because of drug dangerous drug effect,it’s used primarily for treatment of patients with progressive and potentially fatal fungal infections
        • Infusion-related reactions,including fever,shaking chills,hyporension,anorexia,nausea,vomiting,headache,dyspnea and tachypnea,may occur 1-3 hoursafter starting infusion
    • Amphotericin B
      • Nursing Responsibilities:
        • Monitor fluid intake and output; report change in urine appearance or volume.
        • Hydration before infusion may reduce risk of neprotoxicity
        • Monitor potassium levels closely and report signs of hypokalemia
        • Drug is potentially ototoxic. Report evidenced of hearing loss,tinnitus, vertigo or unsteady gait
    • Nystatin (Mycostatin)
      • Drug class :
        • Antifungal
        • Trade name: Mycostatin, Nadostine, Nyaderm
        • Pregnancy Category: C
      • Drug-lab-food Interaction :
        • No significant interactions known
    • Nystatin (Mycostatin)
      • Available Forms:
        • Lozenges:200,000 units
        • Oral suspension:100,000 units/mL
        • Powder: 50,150, or 500 million units; 1,2 0r 5 billions units
        • Tablets: 500,000 units
        • Vaginal Suppositories: 100,000 units
    • Nystatin (Mycostatin)
      • Dosage:
        • A: Topical use as directed
        • Intestinal infection:
        • A: PO: 500,000 – 1,000,000 U t.i.d or q8h
        • Oral candidiasis:
        • A:PO: 400,000 – 600,000 U q6-q8h
        • Neonate (<7 d): PO: 100,000 U q.i.d.
        • C: PO:250,000 – 500,000 U q.i.d.
    • Nystatin (Mycostatin)
      • Indications:
        • Intestinal Candidiasis
        • Oral Candidiasis (thush)
        • vaginal Candidiasis
      • Contraindication:
        • Hypersensitivity
        • Vag: Pregnancy
    • Nystatin (Mycostatin)
      • Pharmacokinetics:
        • Absorption: PO: poorly absorbed
        • Distribution: PB: UK
        • Metabolism t ½ : UK
        • Excretion: in feces unchanged
    • Nystatin (Mycostatin)
      • Pharmacodynamics:
        • Vag:
          • Peak: UK
          • Duration: 6-12 h
        • PO:
          • Onset: Rapid
          • Peak: UK
          • Duration: 6 – 12h
    • Nystatin (Mycostatin)
      • Therapeutic Effects/Uses:
        • To treat Candida infections
        • Mode of Action: Increase Permeability of the fungal cell membrane
      • Side Effects:
        • PO: Anorexia, nausea, vomiting, diarrhea (large doses), stomach cramps, rash
        • Vag: Rash, burning sensation
        • GI: transcient nausea, vomiting, diarrhea
      • Adverse Reaction:
        • None known
    • Nystatin (Mycostatin)
      • Nursing Interventions:
        • Nystatin isn’t effective against systemic infections
        • Vaginal tablets can be used by pregnant patients up to 6 weeks before term to treat maternal infection that may caused oral candidiasis in neonates
    • Nystatin (Mycostatin)
      • Nursing Interventions:
        • For treatment of oral candidiasis: After the mouth is clean of food debris, have patient hold suspension in mouth for several minutes,before swallowing. When treating infanmts,swab medications on oral mucosa. Prescriber may instruct immunosuppresed patients to suck on vaginal tablets (100,000 units) because this provides prolonged contact with oral mucosa
    • Immidazoles Fluconazole (Diflucan) Itraconazale (Sporanox) Ketoconazole ( Sporanox) Miconazole nitrate ( Monistat, Micatin)
    • Fluconazole (Diflucan)
      • Available Forms:
        • Injection: 200mg/mL,400 mg/200 mL
        • Powder for oral suspension: 10mg/mL, 40mg/mL
        • Tablets: 50mg,100mg150mg,200 mg
    • Fluconazole (Diflucan)
      • Route and Dose:
        • A: PO/IV: 200mg x 1 d; maint: 100mg/d for 2 wk
        • C: PO/IV: 3-6 mg/kg/d
      • Uses and Considerations:
        • For a variety of fungal infections. Highly selective inhibitor of fungal cytochrome P- 450. Used to treat cryptococcal meningitis in AIDS clients and oropharyngeal and systemic candidiasis. Pregnancy category: C; PB: 12%; t ½: 20-50h
    • Fluconazole (Diflucan)
      • Indications:
        • Oropharyngeal Candidiasis
        • Esophageal Candidiasis
        • Vulvovaginal Candidiasis
        • Systemic Candidiasis
        • Cryptoccal meningitis
        • Prevention of candidiasis in bone marrow transplant
        • Suppression of relapse of cryptococcal meningitis in patients with AIDS
    • Fluconazole (Diflucan)
      • Contraindication:
        • Contraindicated in patients hypersensitive to drug. Don’t use in breast-feeding patients
    • Fluconazole (Diflucan)
      • Side Effects:
        • CNS; headache,dizziness
        • GI: nausea,vomiting,abdominal pain,diarrhea,dyspepsia,taste perversion
        • HEMATOLOGIC: leukopnea, thrombocytopenia
        • SKIN: Rash
    • Fluconazole (Diflucan)
      • Nursing Interventions:
        • Use cautiously in patients hypersensitive to other antifungal azole compounds; no data exist regarding cross-sensitivity
        • Serious hepatoxicity has occurred in patients with underlying medical conditions
        • Periodically monitor liver function during prolonged therapy
    • Fluconazole (Diflucan)
      • Nursing Interventions:
        • If patients develop mild rash, monitor him closely.
        • Discontinue drug if lesions progress,and notify prescriber.
        • Risk of adverse reactions appears to be greater in HIV-infected patients
    • Itraconazale (Sporanox)
      • Available Forms:
        • Capsules: 100mg
        • Injection:10mg/mL
        • Oral Solution: 10mg/mL
    • Itraconazale (Sporanox)
      • Route and Dose:
        • A: PO: Loading dose: 200mg q8h x 3 d; maint: 200mg/d; max: 400 mg/d in two divided doses.
      •   Uses and Considerations:
        • Effective against various systemic fungal infections, particularly blastomycosis and histoplasmosis. Pregnancy category: C; PB: 99%- t1/2:21-42h.
    • Itraconazale (Sporanox)
      • Indications:
        • Pulmonary and extrapulmonary blastomycosis,nonmeningeal histoplasmosis
        • Aspergillosis
        • Onychomycosis of the toenail
        • Onychomycosis of the fingernail
        • Oropharyngeal Candidiasis
        • Oropharyngeal Candidiasis in patients unresponsive to fluconazole tablets
        • Esophageal Candidiasis
    • Itraconazale (Sporanox)
      • Contraindications:
        • Contraindicated in patients hypersensitive to drugs or receiving oral triazolam or midazolam, in those with ventricular dysfunction or a history of heart failure and in those who are breast-feeding.
    • Itraconazale (Sporanox)
      • Side Effects:
        • CNS: headache,dizziness,somnolence,fatigue,malaise
        • CV: hypertension,edema
        • GI:nausea, vomiting, diarrhea, abdominal pain, anorexia
        • GU: albuminuria, impotence
        • HEPATIC: impaired hepatic function
        • METABOLIC: hypokalemia
        • SKIN: rash,pruritus
    • Itraconazale (Sporanox)
      • Nursing Intervention:
        • Use cautiously in patients with hypochlorhydria; they may not absorb drud readily
        • Because hypochlorhydria can accopmpany HIV infection, use cautiously in HIV-infected patients
        • Use cautiously in patients receiving other highly bound drugs because drug and its metabolites are bound to plasma proteins
    • Itraconazale (Sporanox)
      • Nursing Interventions:
        • Confirm the diagnosis of onychomycosis before starting therapy by having nail specimens undergo appropriate laboratory testing
        • Perform baseline liver function tests and monitor results periodically
    • Ketoconazole (Sporanox)
      • Available Form:
        • Oral Suspension: 100mg/ml
        • Tablets: 200mg
    • Ketoconazole (Sporanox)
      • Route and Dose:
        • A:PO:200-400mg/d as a single dose
        • C: > 20 y: PO: 3.3-6.6 mg/kg/d as single dose
        • C: < 20kg: PO: 50mg/d
      •   Uses and Considerations:
        • For infections by Candida spp. , histoplasmosis, blacstomycosis, and others Treatment could last 1-6 months for systemic infections. Take with food to avoid GI discomfort. Pregnancy category: C; PB: 95%; t 1/2 : 2-8h
    • Ketoconazole (Sporanox)
      • Indications:
        • Systemic Candidiasis, Chronic mucocandidiasis, oral candidiasis, candiduri, coccidiodomycosis, blastomycosis, histoplasmosis, chromomycosis and paracoccidioidomycosis; severe cutaneous dermatophyte infections resistant to therapy with topical or oral griseofulvin
    • Ketoconazole (Sporanox)
      • Contraindications:
        • Contraindicated in patients hypersensitive to drug
    • Ketoconazole (Sporanox)
      • Side Effects:
        • CNS: headache, nervousness, dizziness, somnolence, suicidal tendencies, severe depression
        • EENT: photophobia
        • GI: nausea, vomiting, abdominal pain, diarrhea
    • Ketoconazole (Sporanox)
      • Side Effects:
        • GU: Impotence
        • HEMATOLOGIC: thrombocytopenia, haemolytic anemia, leukopenia
        • HEPATIC : fatal hepatoxicity
        • METABOLIC: hyperlipidemia
        • SKIN: pruritus
    • Ketoconazole (Sporanox)
      • Nursing Interventions:
        • Use cautiously in patients with hepatic disease and in those who are taking other hepetotoxic drugs
        • Because potential for serious hepatoxicity, don’t use ketoconazole for less serious conditions, such as fungal infections of skin or nails
    • Ketoconazole (Sporanox)
      • Nursing Interventions:
        • Monitor patients for signs and symptoms of hepatoxicity including elevated liver enzyme levels, nausea that doesn’t subside and unusual fatigue,jaundice,dark urine,or pale stool
        • Doses up to 800 mg/day can be used to treat fungal meningitis and intracerebral fungal lesions.
    • Miconazole nitrate (Monistat, Micatin)
      • Available Forms:
        • Cream: 2%
        • Powder: 2%
        • Spray: 2%
        • Topical Ointment: 2%
        • Topical Solution: 2%
        • Vaginal
        • Cream: 2%
        • Vaginal Suppositories: 100mg,200mg
    • Miconazole nitrate (Monistat, Micatin)
      • Route and Dose:
        • A: IV: 200-3600 mg/d in D5W in three divided doses; infuse IV over 30-60 min
        • C: IV: 20-40mg/kg/d in divided doses; max: 15mgkg per inf
        • A: Supp: 100mg vag h.s. for 7 d
        • Available: Vaginal cream 2% lotion
    • Miconazole nitrate (Monistat, Micatin)
      • Uses and Considerations:
        • For fungal meningitis and fungal bladder infections. Also for vaginal fungal infections. Pregnancy category: B; PB: 92%; t1/2 2-24h
    • Miconazole nitrate (Monistat, Micatin)
      • Indications:
        • tinea corporis,tinea crusis,tinea pedis; cutaneous candidiasis; common dermatophyte infections
        • tinea versicolor
        • Vulvovaginal candidiasis
    • Miconazole nitrate (Monistat, Micatin)
      • Contraindications:
        • Contraindicated in patients hypersensitive to drug or its components
    • Miconazole nitrate (Monistat, Micatin)
      • Side Effects:
        • CNS: headache
        • GU: pelvic cramps, vulvovaginal burning, pruritus, and irritation with vaginal cream
        • SKIN: irritationb, burning, maceration, allergic contact dermatitis
    • Miconazole nitrate (Monistat, Micatin)
      • Nursing Intervntions:
        • Use together (within 72 hours) of intravaginal forms and certain latex products, such as condoms or vaginal contraceptive diaphragms,isn’t recommended because of possible interaction
        • Don’t use occlusive dressings
        • Lotion should be used in intertriginous areas
    • Antimetabolites Flucytonsine (Ancobon)
    • Flucytonsine (Ancobon)
      • Available Forms:
        • Capsules: 250mg, 500mg
        • Indications Flucytonsine (Ancobon)
    • Flucytonsine (Ancobon)
      • Route and Dose:
        • A: PO: 50-150mg/kg/d in four divided doses.
        • C:>50kg:PO: 50-150mg/kg/d in 4 divided doses.
        • C: < 50kg :PO: 1.5-4.5 g/m 2 /d in four divided doses.
        • C: < 50: PO:1.5-4.5 g/m 2 /d in four divided doses.
        • Neonate: PO: 50-100mg/kg/d in 1-2 divided doses.
    • Flucytonsine (Ancobon)
      • Uses and Contraindication:
        • Use with amphotericin B may increase therapeutic action as well as toxicity. Fungal resistance occurs if the drug is given alone. Pregnancy category: C: PB: UK; t 1/2 : 3-6h
    • Flucytonsine (Ancobon)
      • Indications:
        • Severe fungal infections caused by susceptible strains of Candida species, including septicaemia, endocarditis, urinary tract, and pulmonary infections, and of Cryptococcus species,including meningitis,pulmonary infections, and urinary tract infections
    • Flucytonsine (Ancobon)
      • Contraindications:
        • Contraindicated in patients hypersensitive to drug
    • Flucytonsine (Ancobon)
      • Side Effects:
        • CNS: headache, vertigo, sedation, fatigue, weakness, confusion, hallucinations, psychosis, ataxia, hearing loss, paresthesia, parkinsonism, peripheral neuropathy
        • CV: cardiac arrest, chest pain
    • Flucytonsine (Ancobon)
      • Side Effects:
        • GI: nausea, vomiting, diarrhea, abdominal pain, dry mouth, duodenal ulcer,hemorrhage,ulcerative colitis, anorexia
        • GU: azotemia, crystalluria, renal failure
        • HEMATOLOGIC HEMATOLOGIC: anemia, leukopenia, bone marrow suppression, thrombocytopenia, eosinophilia, agranulocytosis, aplastic anemia
    • Flucytonsine (Ancobon)
      • Side Effects:
        • HEPATIC: jaundice
        • METABOLIC: hypoglycaemia, hypokalemia
        • RESPIRATORY: respiratory arrest, dyspnea
        • SKIN: occasional rash, pruritus, urticaria, photosensitivity
    • Flucytonsine (Ancobon)
      • Nursing Interventions:
        • Use with extreme caution in patients with hepatic or renal function or bone marrow suppression
        • Administer capsules over 15 minutes to reduce reduce adverse GI reactions
        • Monitor blood, liver, and renal function studies frequently during therapy; obtain susceptibility test weekly to monitor drug resistance
    • Flucytonsine (Ancobon)
      • Nursing Interventions:
        • If possible, regularly perform blood level assays of drug, to maintain flucytosine at therapeutic level of 40 to 60 mcg/mL. Blood levels above 100 mcg/mL may be toxic.
        • Monitor fluid intake and output; report marked changes
    • Antiprotozoal Atovaquone (Mepron)
    • Atovaquone (Mepron)
      • Available Forms:
        • Suspension: 750 mg/5 mL
      • Route and Dose:
        • A: PO: 750mg b.i.d. with food x 21d
      •  
    • Atovaquone (Mepron)
      • Uses And Contraindication:
        • For treatment of mid to moderate Pneumocystis carinii pneumonia. Pregnancy category: C; PB: t ½: 2-3d
    • Atovaquone (Mepron)
      • Indications:
        • Acute, mild to moderate Pneumocystis carinii pneumonia in patients who can’t tolerate co-trimoxazole
      • Contraindications:
        • Contraindicated in patients hypersensitive to drug
    • Atovaquone (Mepron)
      • Side Effects:
        • CNS: headache, insomia, asthenia, anxiety, dizziness
        • CV: hypotension
        • EENT: sinusitis, rhinitis
        • GI: nausea, diarrhea, vomiting, constipation, abdominal pain, anorexia, dyspepsia, oral candidiasis, taste perversion
    • Atovaquone (Mepron)
      • Side Effects:
        • HEMATOLOGIC: anemia, neutropenia
        • METABOLIC: hypoglycaemia, hyponatremia
        • RESPIRATORY: cough
        • SKIN: fever, pain
    • Atovaquone (Mepron)
      • Nursing Interventions:
        • Drug has appeared in breast milk. Use cautiously in breast-feeding patients.
        • Because drug is bound to plasma protein, use cautiously with other highly protein-bound drugs, and assess patient for toxicity when used together
        • Alert: Because of risk of concurrent pulmonary infections, monitor patient closely during therapy.
    • THANK YOU FOR LISTENING - GROUP 7
      • The End