Invasive candidiasis

Indication for fluconazole (Mikosist) for invasive candidiasis are: a stable condition of the patient, the absence of prophylactic drugs azolovogo series. Fluconazole is assigned to 400 mg daily, once during the day, intravenously or orally in capsules. When allocating C. glabrata daily dose is doubled to 800 mg per day, receiving the same. In two randomized trials of the effectiveness of treatment of candidemia with fluconazole (400 mg / day) and amphotericin B (0,5-0,6 mg / kg / day) was comparable [14,15]. Due to low toxicity dosing of fluconazole may be increased to 1600 mg per day. The studies demonstrated a dose-dependent clinical effect, however, significant differences in the effectiveness of therapy in case of escalation of the dose was received. Significant toxic manifestations (convulsions, increased blood biochemical parameters) were observed only when using fluconazole at a daily dose of 2000 mg.

Indications for the purpose of amphotericin B are unstable condition of the patient at an unidentified species of yeasts isolated, invasive candidiasis, caused by C. krusei. The daily dose of amphotericin B is 0,7-0,8 mg / kg, the allocation of C. krusei - 1 mg / kg. After stabilization of the states and determine the type of agent, amphotericin B should be replaced by fluconazole.

In severe conditions, or the allocation of fungi resistant to fluconazole, an alternative to amphotericin B may be a form of liposomal amphotericin B or the new antimycotics - voriconazole and caspofungin. Caspofungin is used only intravenously, 70 mg on the first day followed by maintenance dose of 50 mg daily. Voriconazole is administered intravenously on the first day 6 mg / kg every 12 hours, in the coming days - 4 mg / kg every 12 hours, oral application is in the patient's body weight over 40 kg - 400 mg every 12 hours the first day, then - 200 mg every 12 hours, with a body weight less than 40 kg dosage decreases by 2 times.

Indications for liposomal formulations of amphotericin B is renal insufficiency (creatinine brand viagra level in blood serum of adult і221 umol / L, children - і133 umol / l or creatinine clearance <25 ml / min), the ineffectiveness of therapy with amphotericin B after applying it to a total dose і7 mg / kg, significant increases in serum creatinine during therapy with amphotericin B, severe toxic reactions during infusion of amphotericin B. Liposomal amphotericin B applied intravenously at 3-5 mg / kg / day. [12].

C. lusitaniae, C. guilliermondii are resistant to amphotericin B. The drug of choice for these pathogens are fluconazole (400 mg / day.) can be assigned to caspofungin, or voriconazole (in the previously mentioned doses).

The duration of antifungal drugs for candidemia and acute disseminated candidiasis should be at least 2 weeks since the last allocation of yeasts from blood (or lesion) with the full regression of all clinical manifestations of infection. After completion of treatment is recommended to observe the patient for at least 6 weeks because of the possible formation of foci of late hematogenous dissemination (endophthalmitis, osteomyelitis, chronic disseminated candidiasis).

Therapy of Candida endocarditis is a complex, along with the appointment of antimycotics is mandatory surgical treatment: removal of infected heart valves. As initial therapy, amphotericin B is preferred to appoint a maximum tolerable dose - 1,0-1,5 mg / kg. Length of antimycotics after surgical treatment should be at least 6 weeks. For Candida endocarditis is characterized by high relapse rate, so the period of close monitoring of patients is at least 1 year. When it is impossible for surgical treatment is recommended lifelong therapy with fluconazole (200-400 mg / day.) [12].

Treatment of candidal meningitis spend voriconazole (dose - as with candidemia) or amphotericin B (1 mg / kg) or liposomal amphotericin B (5 mg / kg) or fluconazole (400-800 mg) [12]. Because of the possibility of relapse, treatment should be to conduct long-term, at least 4 weeks. Cancel antimycotics should be subject to sterilization of CSF, the elimination of all clinical manifestations of infection, no lesions of the brain substance (control MRI). Keep in mind that sterilization of cerebrospinal fluid is observed earlier eradication of infection in the parenchyma of the brain. Therapy of candidal meningitis associated with neurosurgical treatment involves the removal of foreign material (catheters, shunts) and the appointment of antimycotics.

Prophylaxis

In a number of researchers showcased the benefits of prophylactic use of fluconazole (Mikosist) in surgical patients included in the group of high risk of invasive candidiasis.

The study Eggimann P. c et al. shown that prophylactic fluconazole 400 mg / day for patients with recurrent abdominal operations compared with the control group led to a significant reduction in the frequency of Candida peritonitis (4% vs. 35%, p = 0,02), Candida mucosal colonization (15% vs. 62%, p = 0.04) [16]. Similar results were obtained Pelz R. c et al. the appointment of fluconazole heavy patients after surgery and stay in the ICU for more than 3 days [17].

Thus, prophylactic fluconazole (Mikosist) (400 mg / day.) Justified in patients at high risk of invasive candidiasis: patients with recurrent perforation of the gastrointestinal tract [12.7]. Unjustified prophylactic use of antimycotics in patients with low risk of invasive candidiasis is not only useless but harmful, as can be accompanied by side effects and induce the selection of strains of Candida spp., Refractory to antifungal drugs.

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