242.3 🩺 內科專科考前版

242.3.0.1 1⃣ Echinocandin Step-Down to Fluconazole

  • Empirical echinocandin for invasive candidiasis
  • After 5-7 days + clinical improvement + AST results:
    • Sensitive species (C. albicans, parapsilosis sensitive): step down to fluconazole 400 mg/d PO
    • C. krusei, C. glabrata (often R): continue echinocandin (or voriconazole for C. krusei)
  • Saves cost; transitions to oral
  • Continue 14 days total + monitor

242.3.0.2 2⃣ C. parapsilosis Echinocandin Considerations

  • Some C. parapsilosis isolates have elevated echinocandin MIC (lower susceptibility)
  • AST important
  • Fluconazole often preferred if AST sensitive
  • Echinocandin still works in many cases

242.3.0.3 3⃣ Endocarditis Candida

  • Prosthetic + IVDU primarily
  • Often Candida albicans + parapsilosis
  • TEE for vegetation
  • Surgical valve replacement + AmB + flucytosine 6 wk + chronic fluconazole suppression
  • High mortality even with treatment

242.3.0.4 4⃣ Persistent Candidemia

  • Blood cultures continued positive > 5-7 days on appropriate antifungal
  • Consider:
    • Line still in place (must remove)
    • Endocarditis (TEE)
    • Endophthalmitis
    • Hepatosplenic disseminated
    • Renal abscess
    • Resistance (re-AST)
  • Aggressive workup + source control + extended treatment

242.3.0.5 5⃣ Hepatosplenic Disseminated Candidiasis

  • Post-leukemia chemotherapy
  • Persistent fever + multifocal liver/spleen lesions on imaging
  • Slow response
  • 3-6+ months treatment
  • Echinocandin or azole

242.3.0.6 6⃣ C. auris Outbreak Response

  • Strict contact precautions
  • Cohorting
  • Environmental cleaning (chlorhexidine, sporicidal)
  • Surveillance cultures
  • AST + ID consultation
  • Ch 252 detail

242.3.0.7 7⃣ Pregnancy + Invasive Candidiasis

  • Echinocandin (limited data but used)
  • Liposomal AmB (safe in pregnancy)
  • Avoid fluconazole 1st trimester high-dose
  • Avoid voriconazole (teratogenic concern)

242.3.0.8 8⃣ Risk Stratification for Empirical Therapy

  • Low risk: limited focus, no immune compromise → fluconazole
  • Moderate risk: ICU + multiple RF → echinocandin
  • High risk: neutropenic + mold concern → broader (voriconazole + echinocandin combination, isavuconazole, liposomal AmB)
  • Targeted by source + clinical context

242.3.0.9 9⃣ 健保 / Taiwan

  • 健保 fluconazole, echinocandin, AmB widely covered
  • Rezafungin + ibrexafungerp 健保 ID-restricted indication
  • AST routine in tertiary microbiology
  • ID consultation + ophthalmology + cardiology for severe

242.3.0.10 10. Future + Newer Agents

  • Ibrexafungerp — extending indications
  • Fosmanogepix — broad-spectrum including C. auris
  • Olorofim — limited Candida activity (more for molds)
  • mAb-based therapies in research