Fungal Infections

CONDITION PRIMARY THERAPYFungal Infections  Fungal InfectionsALTERNATIVE THERAPY DURATION COMMENTS

Nongenital Clotrimazole 10 mg Itraconazoleoral Uncomplicated Refractory Oropharyngeal CONDITION troche 5 times dailyPRIMARY THERAPY solution ALTERNATIVE THERAPY disease 7 to 14 DURATION disease: COMMENTS (Oral Thrush) Nongenital OR Clotrimazole 10 mg 200 mg PO once daily Itraconazoleoral days Uncomplicated VoriconazoleRefractory Oropharyngeal Nystatin suspension troche 5 times daily OR solution disease 7 to 14 200 mg PO Q12H disease: (Oral Thrush) POfour timesa day OR Voriconazole 200 mg 200 mg PO once daily days ORVoriconazole OR Nystatin suspension PO Q12HOR L-AmB 200 mg PO Q12HFluconazole PO four times a day Voriconazole 200 mg suspensionOR 1 mL 100–200 mg OR PO Q12H of 100 mg/mLL-AmB PO once dailyFluconazole four timesa daysuspension 1 mL Esophageal Fluconazole 100–200 mg Caspofungin IV 14–21 days Patients unableof 100 mg/mL Candidiasis 200–400 mg PO once daily LD: 70 mg to toleratean oral four times a day Esophageal (3–6 mg/kg) Fluconazole MD: 50 mg Q24HCaspofungin IV 14–21 days agent, IV Patients unable Candidiasis PO Q24H 200–400 mg OR LD: 70 mg fluconazole or to tolerate an oral (3–6 mg/kg) Conventional MD: 50 mg Q24H alternative agent agent, IV PO Q24H Amphotericin BOR listed may be fluconazole or 0.3–0.7 mg/kg IV Conventional used. alternative agent Q24H Amphotericin B listed may be

General SusceptibilityPatterns of Candida spp. 0.3–0.7 mg/kg IV used. Q24H

Fluconazole ItraconazoleGeneral Susceptibility Patterns of Candida spp.

Amphotericin B Caspofungin Voriconazole

Candida albicans S Fluconazole S Itraconazole S Amphotericin

B

S Caspofungin S Voriconazole

C. tropicalisCandida SS albicans C. S parapsilosisC. tropicalis S SS

S S SS

S S SS

S S SS

S S

C. C. glabrata S-DDS S-DD S to R parapsilosis C. krusei R S-DD to R C. glabrata S-DD S-DD to R C. lusitaniae S C. krusei R S S-DD to R S-I S

S-I S-I S to R S-I SS

S S S S S-DD to R S

S S-DD to R S S

H=hour(s);I= Intermediate;IV= intravenous; L-AmB= Liposomal Amphotericin B; LD= loading dose; MD= maintenance dose; PO= by mouth;C. lusitaniae Q=every; R=SResistant; S= S susceptible; S-DD= Susceptibilityis dose S to R dependent;spp=speciesS S

NOTE: Some agentswillrequire IDconsult/approval(amphotericin B, caspofungin, voriconazole). Refer toTable ofContents H= hour(s); I= Intermediate; IV= intravenous; L-AmB= Liposomal Amphotericin B; LD= loading dose; MD= maintenance dose; forsection onGuidelines forRestricted Antibiotics PO= by mouth; Q= every; R= Resistant; S= susceptible; S-DD= Susceptibility is dose dependent; spp= species

NOTE: Some agents will require ID consult/approval (amphotericin B, caspofungin, voriconazole). Refer to Table of Contents for section on Guidelines for Restricted Antibiotics

References:

1. Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016; 62(4):e1-e50.

References:

1. Pappas PG, et al. Clinical Practice Guideline fortheManagement of Candidiasis:2016 Updateby the Infectious Diseases Society of PAGE 8 America. Clin Infect Dis. 2016; 62(4):e1-e50.

Influenza A and B (Flu)  Influenza A and B (Flu)

CLINICALANDTHERAPEUTIC ALGORITHM CLINICALSEVERITY RECOMMENDEDREGIMENS

Diagnosis is based on the clinical presentation of the patient and results of RT-PCR. Decision to initiate treatment should NOT wait for confirmation of laboratory results.

Continue the full course of treatment

if first RT-PCR is negative and if signs and symptoms indicate influenza due to possibility of false negative. History of influenza vaccination does not preclude influenza when signs and symptoms are compatible with the clinical syndrome.

Antiviral treatment recommended as early as possible for patient who (any of the following):

• is hospitalized* • has severe, complicated, or progressive illness* • is at high risk for complications *PO oseltamivir recommended antiviral

High risk complications (any of the following):

• ≥65 years • Chronic health conditions** • Immunosuppression, including caused by medication or HIV infection • Pregnant or postpartum (within 2 weeks of delivery) women (PO oseltamivir preferred for treatment of pregnant women) • American Indian/Alaska Natives • Body mass index ≥40 • Residents of nursing homes and other chronic-care facilities • People younger than 19 years old who are receiving long-term aspirin- or salicylatecontaining medication Zanamivir is not recommended in people with underlying respiratory disease (e.g. asthma, COPD.)

Can consider antiviral treatment previously

healthy, symptomatic outpatient NOT at high

risk based on clinical judgement

(within 48 hours of symptom onset)

Treatment –uncomplicated outpatient

Treatment – severe or complicated outpatient Select ONE of the following:

• Oseltamivir 75 mg PO

Q12H for 5 days • Zanamivir 10 mg (two 5 mg inhalations)

Q12H for 5 days • Peramivir 600 mg IV as a single dose (via >15 minute infusion) • Baloxavir -If 40 - <80 kg: 40 mg PO as a single dose -If ≥80 kg: 80 mg PO as a single dose

Oseltamivir 75 mg PO Q12H for 5 days

Treatment inpatient

Oseltamivir 75 mg PO Q12H for 5 days Notes for treatment: Antivirals should be started as early as possible within 48 hours of symptom onset. May be some benefits for severe, complicated or progressive illness, and in hospitalized patients when started after 48 hours of illness onset. Longer daily dosing (PO oseltamivir or IV peramivir) can be considered for patients who remain severely ill after 5 days of treatment.

Post-Exposure Chemoprophylaxis Select ONE of the following:

• Oseltamivir 75 mg PO once daily • Zanamivir 10 mg (two 5 mg inhalations) once daily Treat for 7 days

Notes for chemoprophylaxis: CDC recommends duration of 7 days (after last known exposure). For control of outbreaks, CDC recommends chemoprophylaxis for a minimum of 2 weeks, and continuing up to 1 week after the last known case was identified.

CDC= Centers for Disease Control and Prevention; COPD= chronic obstructive pulmonary disease; H= Hour(s); HIV= human immunodeficiency virus; PO= by mouth; Q= every; RT-PCR= reverse transcriptase polymerase chain reaction

**Chronic pulmonary (including asthma), cardiovascular (except hypertension alone), renal, hepatic, hematological (including sickle cell disease), metabolic disorders (including diabetes mellitus), neurologic conditions (disorders of the brain, spinal cord, nerve, muscle, epilepsy, stroke, or intellectual disability)

NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients

Based on Renal Function. A reduction in the dose of oseltamivir and peramivir is recommended with renal impairment

References:

1. Centers for Disease Control and Prevention. Influenza Antiviral Medications: Summary for Clinicians. Current for the current for the 2018-2019 influenza season. https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm