Fungal Infections

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Candida species

• Microbiology: C. albicans and nonalbicans species (consider imidazole resistance if prior treatment or nonalbicans species)

• Risk factors: neutropenia, immunosuppression, broad-spectrum abx. intravascular catheters (especially ifTPN). IVDA. abdominal surgery, renal failure

• Clinical manifestations

Mucocutaneous: cutaneous (eg. red. macerated lesions in intertriginous zones); oral thrush (if unexplained, r/o HIV); esophageal (odynophagia; • oral thrush); vulvovaginal Candiduria- typically colonization due to broad-spectrum abx and/or indwelling catheter;

failure to clear raises possibility of upper UTI Candidemia (4th or 5th leading cause of nosocomial blood stream infection): typically due to intravascular catheter: r/o retinal involvement; endocarditis rare (but more common w/ nonalbicans and if prosthetic valve) Hepatosplenic: intestinal seeding of portal & venous circulation; seen in acute leukemics Hematogenous dissemination lung, brain, meninges

Empiric Treatment

Mucocutaneous

Clotrimazole, nystatin, fluconazole, itraconazole

Candidemia w/o neutropenia

Ampho B or fluconazole or caspofungin or [flue - ampho B]

Febrile neutropenia

Ampho B or caspofungin

Remove intravascular catheters (00 2004.38:161)

Histoplasmosis

• Epidemiology: hyperendemic in central & SE U.S. (especially in areas w/ bird & bat droppings), present in river banks including northeast

• Clinical manifestations

Acute pulmonary: often subclinical

Chronic pulmonary: t productive cough, wt loss, night sweats, infiltrates, cavitation Disseminated (immunocompromised): fever, wt loss. HSM. LAN. oral ulcers, skin lesion

• Treatment: itraconazole; amphotericin if severe or disseminated (CiD 2000:30*88)

Coccidioidomycosis

• Epidemiology: SW US. (San Joaquin or "Valley" fever)

• Clinical manifestations

Acute pulmonary: often subclinical; chest pain, cough, fever, arthralgias Chronic pulmonary: cough, hemoptysis, fever, night sweats, wt loss Chronic disseminated (in immunocompromised, pregnant. & diabetics): fever, malaise, diffuse pulmonary process, bone. skin. & meningeal involvement

• Treatment for disseminated or high-risk Y pulmonary: fluconazole or itraconazole, or amphotericin if severe (00 2005:41:1217)

Blastomycosis

• Epidemiology: south central. SE. and midwest U.S.

• Clinical manifestations

Often asymptomatic, acute pneumonia, chronic pneumonia Extrapulmonary: verrucous & ulcerated skin lesions, bone & GU involvement Disseminated: can involve CNS

• Treatment: itraconazole; amphotericin if severe (CiD 2000.30:679)

Aspergillus (Chest 2002:121 1988)

• ABPA: see "Interstitial Lung Disease"

• Hypersensitivity pneumonitis: see "Interstitial Lung Disease"

• Aspcrgilloma: usually in pre-existing cavity (from TB, etc.): most asx. but can lead to hemoptysis; sputum cx © in <50%; CT — mobile intracavitary mass with air crescent Rx: antifungals w/o benefit; embolization or surgery for persistent hemoptysis

• Necrotizing tracheitis: white necrotic pseudomembranes in Pts w/ AIDS or lung tx

• Chronic necrotizing (semi-invasive): seen in COPD or mild immunosuppression;

p/w sputum, fever, wt loss over months; CT shows infiltrate * nodule * pleural thickening; lung bx — invasion; Rx - amphotericin or voriconazole

• Invasive/disseminated: seen if immunocompromised (neutropenia, s/p transplant.

glucocorticoid Rx. AIDS); clinical: s/s pneumonia including chest pain and hemoptysis; CT shows nodules, halo sign, air crescent sign, lung bx if prior testing inconclusive Rx: amphotericin B or voriconazole

URINARY TRACT INFECTIONS (UTI)

Definitions

• Anatomic lower, urethritis, cystitis (superficial infection of bladder) upper pyelonephritis (inflammatory process of the renal parenchyma), renal or perinephric abscess, prostatitis

• Clinical uncomplicated: cystitis in nonpregnant women w/o underlying structural or neurological disease complicated: upper tract infection in women or any UTI in men or pregnant women or UTI with underlying structural disease or immunosuppression

Microbiology

• Uncomplicated UTI: L co/i (80%). Proteus. Klebsiella. S. saprophyttcus (QD 2004:3975)

• Complicated UTI: £ co/i (30%). enterococci (20%). Pseudomonos (20%). S. epidermidis

• Catheter-associated UTI: yeast (30%). £ coli (25%). other GNR. enterococci. S. epi

• Urethritis: Chlamydia trachomatis. Neisseria gonorrhoeae. Ureaplasma urealyticum.

Trichomonas vaginalis. Mycoplasma genitalium, HSV

Clinical manifestations

• Cystitis: dysuria. urgency, frequency. A in urine color/odor, suprapubic pain;

fever generally absent

• Urethritis: may be identical to cystitis except urethral discharge is present

• Prostatitis chronic: similar to cystitis except symptoms of obstruction (hesitancy, weak stream) acute: perineal pain, fever, tenderness on prostate exam

• Pyelonephritis: fever, shaking chills, flank or back pain, nausea, vomiting, diarrhea

• Renal abscess (intrarenal or perinephric): identical to pyelonephritis except persistent fever despite appropriate antibiotics

Diagnostic studies

• Urinalysis: pyuria * bacteriuria - hematuria significant bacterial counts: ^10s CFU/ml in asx women. -10J CFU/ml in men.

CFU/ml in sx or catheterized Pts sterile pyuria — urethritis, renal tuberculosis, foreign body

• Urine Gram stain and cx (from dean-catch midstream or straight-cath specimen)

• Pregnant women & those undergoing urologic surgery screen for asymptomatic bacteriuria

• Blood cultures: in febrile and possibly complicated UTIs

• DNA detection/cx for C. trachomatis/N. gonorrhoeae in sexually active Pts or sterile pyuria

• First-void and midstream urine specimens, prostatic expressate. and post-prostatic massage urine specimens in cases of suspected prostatitis

• Abdominal CT to r/o abscess in Pts with pyelo who fail to defervesce after 72 h

• Urologic workup (renal U/S. abd CT. voiding cystography) if recurrent UTIs in men

Treatment of UTIs

Clinical scenario Cystitis

Empiric treatment guidelines*

FQ or TMP-SMX PO ■ 3 d (uncomplic.) or • 10-14 d (complicated) Asx bacteriuria in pregnant women or prior to urologic surgery abx x 3 d

Urethritis Prostatitis

Treat for both Neisseria and Chlamydia

Neisseria: ceftriaxone 125 mg IM x 1 or levofloxacin 250 mg PO x 1 Chlamydia: doxy 100 mg PO bid x 7 d or azithromycin 1 g PO x 1 FQ or TMP-SMX PO 14-28 d (acute) or 6-12 wks (chronic)

Pyelonephritis

Outpatient: FQ or amoxicillin/clav or oral ceph. PO x 14 d Inpatient: ceftriaxone IV or FQ PO or [amp IV t gent] or ampicillin/sulbactam x 14 d (A IV - PO when Pt improved clinically and afebrile x 24-48 h and then complete 14 d course)

Renal abscess

Drainage • antibiotics as for pyelonephritis

•When possible, organism-directed therapy, guided by in vitro susceptibilities or local patterns of drug resistance should be utilized.

•When possible, organism-directed therapy, guided by in vitro susceptibilities or local patterns of drug resistance should be utilized.

SOFT TISSUE AND BONE INFECTIONS

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