By U. Rune. Neumann College.
Local lymphatic channels and spleen discount zyrtec 5 mg with amex, and other organs and is rapidly fatal if not treated effec- lymph nodes also develop abscesses buy zyrtec 10mg without prescription, nodules, and ulcers that may tively. As with many other infections, the severe, disseminated persist for years if the disease is not treated effectively. In im- form usually occurs in patients whose immune systems are sup- munocompromised people, sporotrichosis may spread to various pressed by diseases or drugs. The various lipid preparations differ in their charac- (CSF) are low with or without inﬂammation. After infusion, second elimination phase, with a half-life of approximately the drug is rapidly taken up by the liver and other organs. It 15 days, which represents elimination from tissue storage is then slowly released back into the bloodstream. Most of the drug is thought to be metabolized in the tis- long-term use, little is known about its distribution and meta- sues; about 5% of the active drug is excreted daily in the bolic pathways. After administration is stopped, amphotericin B can be (eg, pleural, peritoneal, synovial, aqueous, and vitreous hu- detected in the urine for several weeks. Topically to skin lesions two to four times daily for 1–4 wk Oral suspension (100 mg/mL), 1 mL swish and swallow 4 times daily Amphotericin B lipid complex Systemic infections in clients who IV 5 mg/kg/d Same as adults (Abelcet) do not tolerate Fungizone Liposomal amphotericin B Systemic infections in clients who IV 3–5 mg/kg/d Same as adults (AmBisome) do not tolerate Fungizone Empiric treatment of presumed fungal infections in febrile, neu- tropenic clients Amphotericin B cholesteryl Systemic infections in clients who IV, 3–4 mg/kg/d Same as adults (Amphotec) do not tolerate Fungizone Butenaﬁne (Mentax) Tinea infections Topically to skin lesions 1–2 times Safety and efﬁcacy not established daily for 1–4 wk for children <12 y Butoconazole (Femstat, Vaginal candidiasis Intravaginally, once daily for 3 d Gynazole) Caspofungin (Cancidas) Invasive aspergillosis IV infusion over 1 h, 70 mg ini- Safety and efﬁcacy not established tially, then 50 mg daily Hepatic impairment, 70 mg ini- tially, then 35 mg daily Ciclopirox (Loprox) Tinea infections, cutaneous Topically to skin lesions, twice candidiasis daily for 2–4 wk Clotrimazole (Lotrimin, Cutaneous dermatophytosis; Orally, 1 troche dissolved in Same as adults Mycelex, Gyne-Lotrimin) oral, cutaneous, and vaginal mouth ﬁve times daily candidiasis Topically to skin daily for 2–4 wk Intravaginally, once daily for 3–7 d Econazole (Spectazole) Tinea infections, cutaneous Topically to skin lesions, once or Dosage not established candidiasis twice daily for 2–4 wk Fluconazole (Diﬂucan) Oropharyngeal, esophageal, vagi- Oropharyngeal candidiasis, PO, IV Oropharyngeal candidiasis, PO, IV nal, and systemic candidiasis 200 mg ﬁrst day, then 100 mg 6 mg/kg ﬁrst day, then Prevention of candidiasis after daily for 2 wk 3 mg/kg/d for at least 2 wk bone marrow transplantation Esophageal candidiasis, PO, IV, Esophageal candidiasis, PO, IV, Cryptococcal meningitis 200 mg ﬁrst day, then 100 mg 6 mg/kg ﬁrst day, then 3 daily for at least 3 wk mg/kg/d for at least 3 wk CHAPTER 40 ANTIFUNGAL DRUGS 601 Drugs at a Glance: Selected Antifungal Drugs (continued) Routes and Dosage Ranges Generic/Trade Name Clinical Indications Adults Children Vaginal candidiasis, PO 150 mg Systemic candidiasis, PO, IV as a single dose 6–12 mg/kg/d Systemic candidiasis, PO, IV Cryptococcal meningitis, PO, IV 400 mg ﬁrst day, then 200 mg 12 mg/kg ﬁrst day, then daily for at least 4 wk 6 mg/kg/d for 10–12 wk Prophylaxis, PO, IV 400 mg once daily Cryptococcal meningitis, PO, IV, 400 mg ﬁrst day, then 200–400 mg/d for 10–12 wk Flucytosine (Ancobon) Systemic mycoses due to Can- PO 50–150 mg/kg/d in divided Safety and efﬁcacy not established dida species or Cryptococcus doses q6h neoformans Dosage must be decreased with impaired liver function. This reaction does not represent The azoles comprise the largest group of commonly used anti- drug hypersensitivity. Many of these are used topically and some are with acetaminophen, diphenhydramine (an antihistamine), or available without a prescription for dermatologic (see Chap. Nephrotoxicity is the most common and the are used systemically or both topically and systemically. The drug apparently serious, invasive fungal infections, these drugs are often used damages the kidneys by constricting afferent renal arterioles long term following initial treatment with amphotericin B.
Caspofungin dosage must be reduced with fore and during periods of drug-induced neutropenia purchase zyrtec 5mg on-line, often to moderate hepatic impairment; the drug has not been studied prevent recurrence of infection that occurred during previous in clients with severe hepatic impairment proven 5 mg zyrtec. For treatment, oral or IV drugs may be The azole antifungals may cause hepatotoxicity; hepatitis given at the onset of fever and neutropenia, when fever per- occasionally occurs with all of the drugs. Hepatic aminotrans- sists or recurs in a neutropenic client despite appropriate anti- ferases (ALT, AST) and serum bilirubin should be checked be- microbial therapy, or when maintenance therapy is needed fore drug use, after several weeks of drug use, and every 1 to after acute treatment of coccidioidomycosis, cryptococcosis, 2 months during long-term therapy. These infections often relapse if antifungal elevations in ALT and AST may occur. Clients must be closely monitored for ALT increase to more than 3 times the normal range, the azole adverse effects of antifungal drugs. With ﬂuconazole, hepatic dysfunction may range from mild Use in Renal Impairment elevations in ALT and AST to clinical hepatitis, cholestasis, he- patic failure, and death. Fatal hepatic damage has occurred pri- Amphotericin B deoxycholate (Fungizone), the conven- marily in clients with serious underlying conditions, such as tional formulation, is nephrotoxic. Renal impairment occurs AIDS or malignancy, and with multiple concomitant medica- in most clients (up to 80%) within the ﬁrst 2 weeks of therapy tions. Itraconazole is relatively contraindicated in clients with but usually subsides with dosage reduction or drug discontin- increased liver enzymes, active liver disease, or a history of uation. It should be given only if ex- mendations to decrease nephrotoxicity include hydrating pected beneﬁts outweigh risks of liver injury. If the BUN exceeds 40 mg/dL or the serum cre- including toxic hepatitis. Terbinafine has egy is to give a lipid formulation (eg, Abelcet, AmBisome, or been associated with a few cases of liver failure, and its Amphotec), which is less nephrotoxic. For clients who already clearance is reduced by 50% in clients with hepatic cirrho- have renal impairment or other risk factors for development of sis. Its use is not recommended for patients with chronic or renal impairment, a lipid formulation is indicated. Renal func- active liver disease and liver function tests should be done tion should still be monitored frequently.