#416: Antifungals, Candida, Mucorales, Aspergillus, Pneumocystis: The Fungus Among Us with Dr. Ilan Schwartz MD
Nov 20, 2023
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A discussion with Dr. Ilan Schwartz, an expert in fungal infections, covers topics like when to worry about fungal infections, starting anti-fungals, testing basics, resistant candida, and Pneumocystis jiroveci pneumonia. The episode also touches on MRI priorities for surgeons, unique holiday gifts, and the challenges of treating Candida and Canada-Oris.
Prompt recognition and appropriate management are crucial in invasive fungal infections, especially in medically and surgically complex patients.
Candida auris is a concerning fungal pathogen due to its ability to form biofilms and resistance to antifungals, requiring vigilant infection prevention and control measures.
Pneumocystis pneumonia can occur in patients on immunosuppressive therapies, and prophylaxis is recommended for high-risk patients.
Deep dives
Invasive fungal infections and their risk factors
Invasive fungal infections, such as invasive candidiasis and mucormycosis, are a concern in medically and surgically complex patients. Risk factors include surgery, central venous catheters, broad-spectrum antibiotics, mucositis, neutropenia, and more. Prompt recognition and appropriate management are crucial.
Candida auris and the threat of resistant fungal organisms
Candida auris is a commensal of the skin that is causing concern due to its ability to form biofilms and its resistance to antifungals. It is difficult to control and eradicate, making it an urgent antimicrobial resistance threat. Vigilant infection prevention and control measures are crucial to containing its spread.
Pneumocystis pneumonia and its risk factors
Pneumocystis pneumonia (PJP) is not exclusive to HIV patients and can occur in patients on immunosuppressive therapies, such as steroids and organ transplant recipients. Prophylaxis is recommended for high-risk patients, and prompt recognition is important for early management.
Importance of Prompt Diagnosis and Treatment in Fungal Infections
In this podcast episode, the speakers discuss the importance of prompt diagnosis and treatment in fungal infections. They highlight the need for clinicians to consider different fungal pathogens based on the patient's clinical presentation and risk factors. Specific examples of fungal infections, such as invasive candidiasis, mucor mycosis, and aspergillosis, are discussed, along with the appropriate first-line medications for each. The speakers also cover the diagnostic tests available for fungal infections, including cultures, PCR, and indirect biomarkers. They emphasize the importance of interpreting test results in the context of pretest probabilities and consulting with infectious disease specialists.
Management of Fungal Endocarditis and Pneumocystis Pneumonia
The podcast episode delves into the management of fungal endocarditis and pneumocystis pneumonia. The speakers emphasize the challenges of treating fungal endocarditis, including the need for surgical intervention in many cases. They discuss the use of antifungal medications, such as amphotericin B and azoles, for a prolonged period. The importance of consulting with cardiovascular surgeons is highlighted. For pneumocystis pneumonia, the first-line treatment is trimethoprim-sulfamethoxazole (TMPS-SMX), with consideration for the addition of corticosteroids in moderate to severe disease. Diagnostic methods, including histopathology, BAL testing, and PCR, are also addressed, with an emphasis on interpreting results based on pretest probabilities and clinical presentation.
“I collect spores, molds and fungus” - Dr. Egon Spengler
Dr. Ilan Schwartz MD PhD (@GermHunterMD) teaches us that we should always at least consider fungi in the differential diagnosis of unexplained sepsis, especially in patients with impaired immune systems or complex medical or surgical histories, and walks us through an approach to antifungals. Be sure to check out the Mycoses Study Group Education & Research Consortium (@MSG_ERC), an organization of clinicians who are dedicated to advancing diagnostics and treatment of fungal disease (where Dr. Schwartz serves on the board of directors!) Claim CME for this episode at curbsiders.vcuhealth.org!
Intentionally vague case; When should we be worried about fungal infection?
Overnight emergencies: Candidiasis and mucormycosis
Starting empiric anti-fungals
Testing basics: direct versus indirect
Fungemia, fungal endocarditis
Resistant candida; candida auris
Pneumocystis jiroveci pneumonia
Outro
Credits
Producer, Writer, Show Notes, Infographic/Cover Art: Beth Garbitelli MD
Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP, Beth Garbitelli MD
Reviewer: Emi Okamoto MD
Showrunners: Matthew Watto MD, FACP; Paul Williams MD, FACP
Technical Production: PodPaste
Guest: Ilan Schwartz MD, PhD
Transcript Disclaimer
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