1. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 41 Antifungal Drugs

2. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antifungal Drugs: Definition Drugs used to treat infections caused by fungi  Systemic  Topical

3. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Fungi  Very large and diverse group of microorganisms  Broken down into yeasts and molds  Fungal infections also known as mycoses  Some fungi are part of the normal flora of the skin, mouth, intestines, vagina

4. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Yeasts  Single-cell fungi  Reproduce by budding  Can be used for  Baking  Alcoholic beverages

5. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Molds  Multicellular  Characterized by long, branching filaments called hyphae

6. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Mycotic Infections Four general types  Cutaneous  Subcutaneous  Superficial  Systemic* *Can be life threatening *Usually occur in immunocompromised host

7. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Mycotic Infections (cont’d) Candida albicans  Due to antibiotic therapy, antineoplastics, or immunosuppressants (corticosteroids)  May result in overgrowth and systemic infections  Growth in the mouth is called thrush or oral candidiasis  Common in newborn infants and immunocompromised patients

8. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Mycotic Infections (cont’d) Vaginal candidiasis  “Yeast infection”  Pregnancy, women with diabetes mellitus, women taking oral contraceptives

9. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antifungal Drugs Systemic  amphotericin B, caspofungin, fluconazole, ketoconazole, others Topical  Examples: clotrimazole, miconazole, nystatin

10. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antifungal Drugs (cont’d) Broken down into major groups based on their mechanisms of action  Polyenes: amphotericin B and nystatin  Imidazoles: ketoconazole  Triazoles: fluconazole, itraconazole  Echinocandins: caspofungin, micafungin  Listed individually, not by mechanism of action:  griseofulvin, flucytosine

11. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Mechanism of Action Polyenes: amphotericin B and nystatin  Bind to sterols in cell membrane lining  Result: fungal cell death  Do not bind to human cell membranes or kill human cells

12. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Mechanism of Action (cont’d) flucytosine  Also known as 5-fluorocytosine (antimetabolite)  Taken up by fungal cells and interferes with DNA synthesis  Result: fungal cell death

13. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Mechanism of Action (cont’d) Imidazoles and triazoles: ketoconazole, fluconazole  Inhibit fungal cell cytochrome P-450 enzymes, resulting in cell membrane leaking  Lead to altered cell membrane  Result: fungal cell death

14. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Mechanism of Action (cont’d) griseofulvin  Disrupts cell division  Result: inhibited fungal mitosis (reproduction)

15. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Mechanism of Action (cont’d) Echinocandins: capsofungin, micafungin  Prevent the synthesis of glucans, which are essential components of fungal cell walls  Causes fungal cell death

16. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Indications  Systemic and topical fungal infections  Drug of choice for the treatment of many severe systemic fungal infections is amphotericin B  Choice of drug depends on type and location of infection

17. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Adverse Effects: Amphotericin B  Fever  Headache  Malaise  Hypotension  Muscle and joint pain  Lowered potassium and magnesium levels  Chills  Dysrhythmias  Nausea  Anorexia

18. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Adverse Effects: Amphotericin B (cont’d)  Main concerns:  *Renal toxicity  *Neurotoxicity: seizures and paresthesias  Many other adverse effects

19. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antifungal Drugs: Adverse Effects (cont’d) fluconazole  Nausea, vomiting, diarrhea, stomach pain,  increased liver function studies flucytosine  Nausea, vomiting, anorexia, headache, dizziness, others griseofulvin  Rash, urticaria, headache, nausea, vomiting, anorexia, others

20. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antifungal Drugs: Contraindications Liver failure Renal failure Porphyria (griseofulvin)

21. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antifungal Drugs: Interactions  Many antifungal drugs are metabolized by the cytochrome P-450 enzyme system  Coadministration of two drugs that are metabolized by this system may result in competition for these enzymes, and thus higher levels of one of the drugs

22. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications  Before beginning therapy, assess for hypersensitivity, possible contraindications, and conditions that require cautious use  Obtain baseline VS, CBC, liver and renal function studies, and ECG  Assess for other medications used (prescribed and OTC) in order to avoid drug interactions

23. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Follow manufacturer’s directions carefully for reconstitution and administration  Monitor VS of patients receiving IV infusions every 15 to 30 minutes  During IV infusions, monitor I&O to identify adverse effects

24. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d) amphotericin B  To reduce the severity of the infusion-related reactions, pretreatment with an antipyretic (acetaminophen), antihistamines, antiemetics, and corticosteroid may be given  Use IV infusion pumps and the most distal veins possible

25. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Some oral forms should be given with meals to decrease GI upset; others require an empty stomach—be sure to check

26. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Nystatin given as an oral lozenge or troche should be slowly and completely dissolved in the mouth (not chewed or swallowed whole)  Nystatin suspension should be swished thoroughly in the mouth as long as possible before swallowing

27. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d) Monitor for therapeutic effects  Easing of the symptoms of infection  Improved energy levels  Normal vital signs, including temperature Monitor carefully for adverse effects