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12.03 Anti-Infective – Antifungals

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Overview

     I.        
Overview

A.    Yeasts and molds

B.    Systemic vs. topical

C.     Mechanism of Action

1.     Depends on drug subclass

a.     Interferes with fungal DNA synthesis

b.     Interferes with reproduction

                                                                              i.         Inhibition of cell growth

                                                                             ii.         Cell death

D.    Types

1.     Amphotericin B

2.     Fluconazole

3.     Itraconazole

4.     Ketoconazole

5.     Clotrimazole

6.     Voriconazole

7.     Miconazole

8.     Micafungin

9.     Caspofungin

10.  Nystatin

11.  Terbinafine

12.  Flucytosine

13.  Griseofulvin

     II.          II. Indications

A.    Cutaneous and Subcutaneous Mycoses 

1.     Epidermophyton spp.

2.     Malassezia furfur (causes tinea versicolor)

3.     Microsporum spp.

4.     Sporothrix spp.

5.     Trichophyton spp.

B.    Systemic Mycoses 

1.     Absidia spp.

2.     Aspergillus spp.

3.     Basidiobolus spp.

4.     Blastomyces dermatitidis

5.     Candida spp.

6.     Coccidioides immitis

7.     Conidiobolus spp.

8.     Cryptococcus neoformans

9.     Histoplasma capsulatum

10.  Mucor spp. Rhizopus spp.

11.  Scedosporium apiospermum

   III.         III. Contraindications

A.    Drug allergy

B.    Liver failure

C.     Kidney failure

D.    Porphyria (griseofulvin)

E.     Itraconazole

1.     Severe cardiac problems

F.     Voriconazole

1.     Pregnant women

   IV.         IV. Interactions

A.    Digoxin

B.    Oral anticoagulants

C.     Oral hypoglycemics

D.    Nephrotoxicity

E.     Hepatoxicity

F.     Thiazide diuretics

G.    Oral contraceptives

    V.         V. Side Effects

A.    Amphotericin B

1.     Cardiac dysrhythmias

2.     Pulmonary infiltrates

3.     Renal

a.     Renal toxicity

b.     Potassium loss

c.     Hypomagnesemia

4.     CNS

a.     Neurotoxitcity

b.     Visual disturbances

c.     Numbness

d.     Tingling

e.     Convulsions

5.     Other

a.     Fever

b.     Chills

c.     Headache

d.     N / V

e.     Hypotension

B.    Fluconazole

1.     GI

a.     N / V/ D

b.     Stomach pain

2.     Increased AST/ALT levels

C.     Flucytosine

1.     Hematologic

a.     Bone marrow suppression

b.     Thrombocytopenia

c.     Agranulocytosis

d.     Anemia

e.     Leukopenia

f.      Pancytopenia

2.     GI

a.     N / V/ D

b.     Anorexia

c.     Abdominal distension

d.     Cramps

e.     Enterocolitis

3.     CNS

a.     Headache

b.     Confusion

c.     Dizziness

d.     Sedation

e.     Vertigo

4.     Other

a.     Increased BUN / creatinine

b.     Increased AST / ALT

c.     Rash

D.    Griseofulvin

1.     CNS

a.     Headache

b.     Peripheral neuritis

c.     Confusion

d.     Dizziness

e.     Fatigue

f.      Insomnia

g.     Psychosis

2.     EENT

a.     Blurred vision

b.     Oral candidiasis

c.     Furry tongue

d.     Transient hearing loss

3.     Integumentary

a.     Rash

b.     Urticaria

c.     Photosensitivity

d.     Angioedema

e.     SLE

4.     Hematologic

a.     Leukopenia

b.     Granulocytopenia

c.     Neutropenia

d.     Monocytosis

5.     GU

a.     Proteinuria

b.     Porphyria

6.     GI

a.     N / V / D

b.     Anorexia

c.     Cramps

d.     Dry mouth

e.     Flatulence

f.      Increased thirst

g.     Dysgeusia

E.     Itraconazole

1.     Integumentary

a.     Pruritis

b.     Fever

c.     Rash

2.     GU

a.     Gynecomastia

b.     Impotence

c.     Decreased libido

3.     GI

a.     N / V / D

b.     Cramps

c.     Abdominal pain

d.     Flatulence

e.     GI Bleeding

f.      Hepatotoxicity

4.     CNS

a.     Headache

b.     Dizziness

c.     Insomnia

d.     Somnolence

e.     Depression

5.     Other

a.     Edema

b.     Fatigue

c.     Malaise

d.     HTN

e.     Hypokalemia

f.      Tinnitus

g.     Hypertriglyceridemia

h.     Adrenal insufficiency

F.     Ketoconazole

1.     CNS

a.     Headache

b.     Dizziness

c.     Somnolence

d.     SIADH

2.     GI

a.     N / V / D

b.     Abdominal pain

c.     Hepatotoxicity

3.     GU

a.     Gynecomastia

b.     Impotence

c.     Vaginal burning

4.     Hematologic

a.     Thrombocytopenia

b.     Leukopenia

c.     Hemolytic anemia

5.     Integumentary

a.     Pruritus

b.     Fever

c.     Chills

d.     Photophobia

e.     Rash

f.      Dermatitis

g.     Purpura

h.     Urticaria

6.     Other

a.     Hypoadrenalism

b.     Hyperuricemia

c.     Hypothyroidism

G.    Nystatin

1.     GI

a.     N/ V / D

b.     Anorexia

c.     Cramps

2.     Integumentary

a.     Rash

b.     Urticaria

H.    Terbinafine

1.     CNS

a.     Headache

b.     Dizziness

2.     GI

a.     N / V / D

3.     Integumentary

a.     Rash

b.     Pruritus

Nursing Points

Nursing Concepts

I. Infection Control
II. Pharmacology

Patient Education

I. Notify provider if taking a medication that can interact
II. Notify if any of the contraindications

Reference Links

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Video Transcript

Hey there, today we are going to discuss antifungals and their background.

Antifungals are used to treat yeasts and mold, which can be systemic or topical. The mechanisms of actions varying, depending on drug subclass but include: DNA synthesis interference, reproduction interference and  inhibition of cell growth. All of which cause cell death.

How antifungals are a large drug group, with many endings. But the two common ones are -AZOLE and -FUNGIN. In the inpatient health care setting, you will likely see these two endings.

Now, take a deep breath… I know the indications are plentiful but let’s do a quick overview. Remember when I mentioned yeasts and molds in the beginning? That is what I want you to focus on. The species mentioned on the slide are specific types of yeasts and molds. Don’t let that confuse you. For example: Candida… it’s a yeast infection. Don’t overthink it.

Contraindications for the general antifungal group consists of drug allergy, liver and kidne failure. With griseofulvin, patients with porphyria is a contraindication. And with voriconazole, patients who are pregnant shouldn’t receive this antifungal medication d/t fetal toxicity. Lastly with itraconazole, patient with severe cardiac problems who avoid this medication as well d/t it inducing heart failure. An easy way to remember this is DLK GVI.

Interactions with antifungal infections in hepatotoxic drugs, oral contraceptives (decreased OC effectiveness), thiazide diuretics (severe hypocalcemia / hypokalemia), digitalis toxicity, oral anticoagulants (decreased AC effectiveness), oral hypoglycemics (reduced effectiveness)  and nephrotoxic drugs. To remember interactions, use HOT DOON.

Amphotericin B side effects include cardiac dysrhythmias, pulmonary infiltrates, renal & electrolyte dysfunction, CNS symptoms (neurotoxicity, visual disturbances, numbness, tingling, convulsions) and other, which includes, fever, chills, HA, N/V and hypotension.

Fluconazole side effects are GI related and include N/V/D, stomach pain and increased AST/ALT which are related to liver dysfunction.

Side effects of flucytosine include GI (N/V/D, anorexia, abdominal pain, cramps, enterocolitis), hematologic – bone marrow suppression, thrombocytopenia, agranulocytosis, anemia, leukopenia and pancytopenia. CNS which include HA, confusion, dizziness, sedation and vertigo. And other, which include increased BUN/creat, increased AST/ALT and rash.

Side effects for griseofulvin include EENT – blurred vision, oral candidiasis, furry tongue and transient hearing loss. CNS – HA, neuritis, confusion, dizziness, fatigue, insomnia and psychosis. GU – proteinuria. Hematologic – leukopenia, neutropenia and granulocytopenia. GI – N/V/D, anorexia and flatulence. Lastly, we have integumentary – rash, urticaria and angioedema.

Side effects for itraconazole include, GI – N/V/D, cramps, abdominal pain, flatulence, GIB, hepatotoxicity. CNS – HA, dizziness, somnolence, depression, insomnia, fatigue, malaise. GU – Gynecomastia, impotence, decreased libido. Integumentary – Rash, fever, pruritus. And the last section is other, which includes edema, HTN, hypokalemia, tinnitus, high triglycerides and adrenal insufficiency.

Side effects for ketoconazole include CNS – HA, dizziness, somnolence, SIADH. GU – Gynecomastia, impotence and vaginal burning. GI – N/V/D, abdominal pain and hepatotoxicity. Integumentary – pruritic, photophobia, rash, dermatitis and urticaria. Hematologic – Thrombocytopenia, leukopenia and hemolytic anemia. And other – Hypoadrenalism, hyperuricemia and hypothyroidism.

Side effects are nystatin are brief and include rash, urticaria, N/V/D, anorexia and cramps.

Side effects are terbinafine are brief and include HA, dizziness, rash, pruritus, and N/V/D.

Now, we just reviewed many, many side effects… did you see any trends or patterns? Yes! GI, GU, CNS, heme and skin. Antifungals have many side effects with impact being organ based. Effects are based on topical vs systemic application and excretion site (i.e. kidney, liver etc.) The point being proper monitoring is crucial in this medication class as they have varying side effects.

Priority nursing concepts for antifungals include pharmacology and infection control.

Alright let’s recap. antifungals are various endings with 2 common ones being -AZOLE and -FUNGIN. Indications varying types of mycoses. 

Contraindications for the general antifungal group consists of drug allergy, liver and kidney failure. With griseofulvin, patients with porphyria is a contraindication. And with voriconazole, patients who are pregnant shouldn’t receive this antifungal medication d/t fetal toxicity. Lastly with itraconazole, patient with severe cardiac problems who avoid this medication as well d/t it inducing heart failure. An easy way to remember this is DLK GVI.

Now, we just reviewed many, many side effects… did you see any trends or patterns? Yes! GI, GU, CNS, heme and skin. Antifungals have many side effects with impact being organ based. Effects are based on topical vs systemic application and excretion site (i.e. kidney, liver etc.) The point being proper monitoring is crucial in this medication class as they have varying side effects.How would you assess GU? That’s right renal labs (BUN/cret). You assess skin with physical assessments and Heme with an H&H.

Interactions with antifungal infections in hepatotoxic drugs, oral contraceptives (decreased OC effectiveness), thiazide diuretics (severe hypocalcemia / hypokalemia), digitalis toxicity, oral anticoagulants (decreased AC effectiveness), oral hypoglycemia

You know now the important details regarding antifungals. Now, go out and be your best self today and as always, Happy Nursing!

  • Question 1 of 5

A client is being prescribed an antifungal medication and the nurse knows that a contraindication for this drug includes which of the following?

  • Question 2 of 5

A client is prescribed voriconazole and the nurse knows this medication is contraindicated in which of the following client populations?

  • Question 3 of 5

A nursing student is studying antifungals and knows that antifungals have which of the following suffixes? Select all that apply.

  • Question 4 of 5

If a client is taking an antifungal medication and thiazide diuretics, which of the following electrolyte disturbances would the nurse expect to find?

  • Question 5 of 5

The nurse is caring for a client receiving an antifungal and knows that which of the following interactions occur with this drug class?

Module 0 – Pharmacology Course Introduction
Module 3 – Disease Specific Medications

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