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Common Settings for Nosocomial Fungal Infections
Neonatal intensive care unit
Neutropenic cancer patients
Bone marrow transplant patients
HIV infection
Intravascular catheters
Other predisposing
Infections with Candida Species
Predisposing conditions
Change in intestinal flora
Prolonged antibiotic therapy
Oral contraceptives
Breach of Epithelial Barrier
Catheters - intravascular, intraperitoneal, urinary
Burns
Surgery
Hyperglycemia
Diabetes
Steroids
Genetic Defects of Neutrophil Function
Chronic granulomatous disease
Myeloperoxidase deficiency
Nosocomial Fungi
Order of Frequency
C albicans
C tropicalis - catheters c. C. parapsilosis - NICU
C krusei- Bone marrow transplant patients on fluconazole prophylaxis
C glabrata, lusitaneii, guillermondii
Associated Physical Findings
Rash - isolated
Microbiology
a. Isolator
b. Induction of germ tubes in 20% serum - C. albicans
c. Fungal sensitivities - test Amphotericin B, fluconazole, 5-FC
5. therapy - choice must be tied to gravity of infection and degree of immunocompromise a. local infection
a. Stoma site: Clotrimazole powder
b. Vaginitis: Clotrimazole trochees or ointment
6. Locally Invasive Disease
a. Esophagitis:
(1) Amphotericin B, 0.3 mg/kg/day
(2) Fluconazole if sensitive
b. Peritonitis 2° dialysis catheter
c. Cystitis in catheterized patient - irrigation with 50 mg/L
7. Systemic Disease
a. Amphotericin B at 1.0 mg/kg
b. Remove catheter
c. Ascertain degree of dissemination: ophthalmologic exam, liver/spleen renal ultrasound
C. Aspergillus
1. Pre-disposing conditions
a. Bone marrow transplant
b. Prolonged neutropenia
c. Asthma for allergic bronchopulmonary aspergillosis
d. Cavitary lung disease for aspergilloma
2. Species Encountered
a. Aspergillus niger
b. Aspergillus flavus
c. Aspergillus terreus
3. Associated Physical Findings
a. Black eschar on exam of nares
b. Black eschar at skin site
c. Tachypnea and dyspnea
4. Diagnostic Issues
a. Requires >7 days to grow b. biopsy most rapid means of diagnosis - look for septate hyphae c. CT of chest more sensitive for nodular infiltrates than CXR d. sinus films and ENT exam
5. Therapy
a. Amphotericin B - 1.5 mg/kg/day
b. addition of 5 FC or Rifampin now displaced by Itraconazole
D. Mucormycoses
2. Species Encountered
a. Rhizopus
b. Mucor
3. Associated Physical Findings
a. Black eschar in nose
b. Black eschar on skin
c. Direct inhalation: pneumonia
4. Diagnostic Issues
a. Biopsy required - look for non-septate hyphae
5. Anti-fungal Therapy
a. Successful therapy requires wide surgical debridement
b. Amphotericin B at