~Teachingcenter的醫學筆記~

真菌的治療

治療藥物

1. 表皮性黴菌、表淺性黴菌病
   • 角質溶解劑：salicylic acid、thiosulfate
   • 局部抗黴菌藥：miconazole nitrate
   • 廣泛性感染時，可以使用griseofulvin + miconazole (2%)
2. 下表皮黴菌病(subcutaneous mycoses)
   • Sporotrichosis：Amphotericin B
   • Mycetoma：細菌引起的可以用磺胺類藥物

念珠菌菌血症(candidemia)的治療
※強烈建議移除所有靜脈內管路！
沒有嗜中性球低下(candidemia in non-neutropenic patients)

1. Empiric therapy
   • Mild illness without recent azole exposure: Fluconazole
   • Moderate to severe illness or recent azole exposure: Amphotericin B deoxycholate, Micafungin (Micafungin may reserve for poor renal function or can’t tolerance Amphotericin B deoxycholate.)
   • Alternative use:
     1. Caspofungin
     2. Voriconazole- step-down oral therapy for selected cases of candidiasis due to Candida krusei or Voriconazole-susceptible C. glabrata.
2. Definitive use
   • C. albicans or C. tropicalis: Fluconazole
   • C. parapsilosis:
     1. Drug of choice: Fluconazole
     2. Alternative use: Amphotericin B deoxycholate or Voriconazole
     3. For patients who have initially received one therapy and are clinically improved, and whose follow-up culture results are negative, continuing use of this therapy is reasonable.
   • C. glabrata:
     1. Drug of choice: Micafungin
     2. Alternative use: Amphotericin B deoxycholate or Caspofungin
     3. For patients who have initially received one therapy and are clinically improved, and whose follow-up culture results are negative, continuing use of this therapy is reasonable.
   • C. krusei:
     1. Drug of choice: Micafungin
     2. Alternative use: Amphotericin B deoxycholate, Variconazole or Caspofungin

合併嗜中性球低下(candidemia in neutropenic patients)

1. Empiric therapy
   • Drug of choice: Amphotericin B deoxycholate or Caspofungin
   • Alternative: Voriconazole or Micafungin or Itraconazole
2. Definitive use
   • C. tropicalis or other culture: continue current therapy
   • For patients who have initially received one therapy and are clinically improved, and whose follow-up culture results are negative, continuing use of this therapy is reasonable.
   • C. parapsilosis:
     1. Drug of choice: Fluconazole
     2. Alternative use: Amphotericin B deoxycholate or Voriconazole
   • C. glabrata:
     1. Drug of choice: Micafungin
     2. Alternative use: Amphotericin B deoxycholate or Caspofungin
   • C. krusei:
     1. Drug of choice: Micafungin
     2. Alternative use: Amphotericin B deoxycholate, Variconazole or Caspofungin

※請依照病人臨床表現與症狀進行藥物選擇與劑量等調整

Duration of therapy for candidemia without obvious metastatic complications is for 2 weeks after documented clearance of candida from the bloodstream and resolution of symptoms attributable to candidemia.

預防性抗真菌藥物使用(prophylaxis)：

1. Solid-organ transplant recipients
   • Fluconazole 400mg QD or
   • LFAmB (lipid formulation of amphotericin B) 1~2mg/kg QD for 7~14 days
2. Patient hospitalize in the ICU
   • Fluconazole 400mg QD is recommended.
3. Patient with chemotherapy induced neutropenia
   • Fluconazole 400mg QD or
   • Posaconazole 200mg TID or
   • Caspofungin 50mg QD
   • Oral Itraconazole 200mg BID is an effective alternative.
4. Stem cell transplant recipients with neutropenia
   • Fluconazole 400mg QD or
   • Posaconazole 200mg TID or
   • Micafungin 50mg QD

抗真菌機轉及其對應的藥物

1. 抑制DNA及RNA合成
   • Ciclopirox (與iron-dependent mitochondrial enzyme結合)
   • Flucytosine
2. 與DNA結合
   • Metronidazole
3. 與RNA結合
   • Griseofulvin
4. 抑制細胞壁的合成Echinocandin
   • Caspofungin
   • Micafungin
   • Anidulafungin
5. 抑制c14-alpha-demethylase
   • Ketoconazole
   • Itraconazole
   • Fluconazole
   • Miconazole
   • Posaconazole
   • Voriconazole
   • Butoconazole Nitrate
   • Clotrimazole
   • Econazole
   • Oxiconazole
   • Sertaconazole Nitrate
   • Sulconazole
   • Tioconazole
   • Terconazole
6. 與細胞膜結合，破壞完整性
   • Natamycin
7. 與ergosterol結合
   • Amphotercin B
   • Nnystatin
8. 抑制squalene epoxidase
   • Terbinafine
9. 破壞細胞膜結構
   • Tolnaftate
   • Tolciclate
10. 抑制delta-7,8 reductase
    • Amorolfine