241.2 📚 國考版

241.2.0.1 必背 — 5 Major Antifungal Classes

Class Drug Mechanism
Polyenes Amphotericin B Ergosterol binding → membrane pores
Azoles Fluconazole, voriconazole, posaconazole, isavuconazole Inhibit CYP51 (lanosterol 14α-demethylase)
Echinocandins Caspofungin, micafungin, anidulafungin, rezafungin Inhibit β-1,3-glucan synthase
Pyrimidine Flucytosine DNA synthesis inhibition
Allylamines Terbinafine Inhibit squalene epoxidase

241.2.0.2 必背 — Antifungal Drug of Choice

Pathogen First-Line
Invasive Candida Echinocandin (caspofungin/micafungin/rezafungin)
C. albicans azole-sensitive Fluconazole (step-down)
C. krusei (intrinsic flu R) Echinocandin / voriconazole
C. glabrata (variable flu R) Echinocandin
C. auris Echinocandin (some R; need AST)
Aspergillus invasive Voriconazole or isavuconazole
Cryptococcal meningitis Amphotericin B + flucytosine (induction); fluconazole maintenance
Mucormycosis Amphotericin B (liposomal) + isavuconazole or posaconazole
Histoplasmosis Itraconazole (mild-moderate); amphotericin B (severe)
Pneumocystis TMP-SMX (Ch 218)
Vulvovaginal Candida Fluconazole 150 mg PO × 1 or topical azoles
Sporothrix Itraconazole; iodide
Dermatophytes Terbinafine / azoles

241.2.0.3 必背 — Spectrum Gaps

  • Echinocandins: NO Cryptococcus, Mucor, Fusarium
  • Fluconazole: NO Mucor, weakly active Aspergillus
  • Voriconazole: NO Mucor
  • Posaconazole: Yes Mucor + broad mold spectrum
  • Isavuconazole: Yes Mucor + broad
  • Amphotericin: Broad (but not Lomentospora, Pseudallescheria)

241.2.0.4 必背 — TDM Drugs

  • Voriconazole, posaconazole (especially suspension), itraconazole, flucytosine
  • Echinocandins + fluconazole + isavuconazole — no routine TDM

241.2.0.5 必背 — New Drugs (2021-2024)

  • Rezafungin (Rezzayo 2023): once-weekly echinocandin
  • Ibrexafungerp (Brexafemme 2021): oral triterpenoid for VVC
  • Olorofim (Phase 3): orotomide for resistant mold
  • Fosmanogepix (Phase 3): broad-spectrum

241.2.0.6 必背 — Amphotericin B Toxicity

  • Nephrotoxicity + electrolyte wasting (K+, Mg2+) — major
  • Infusion reactions (pre-medicate)
  • Liposomal less toxic than conventional

241.2.0.7 必背 — Voriconazole Special

  • Visual disturbances (transient)
  • Hepatotoxicity
  • QTc prolongation
  • Periostitis + cutaneous SCC (chronic)
  • TDM essential

241.2.0.8 必背 — Pregnancy + Antifungals

  • Avoid high-dose fluconazole 1st trimester (teratogenic)
  • Single low-dose 150 mg for VVC generally OK
  • Echinocandins limited data; use if needed
  • Amphotericin B safer in pregnancy