Download Clinical Case #21

Clinical Case #21
M. James Ortiz
Case #21

Baby girl Ciara, 3 months of age, born
at the Rural Health Center, was seen at
Fatima because of white spot in the
tongue and buccal mucosa described
by her mother as remaining milk curds.

Working Diagnosis: Oral Candidiasis
Questions:




What are the drugs you would prescribe?
Mechanism of action of your drug regimen.
How would you give the medication?
What other advice would you give to the
parents/guardian of your patient?
What is Oral Candidiasis?

Oral Candidiasis (oral thrush) is a superficial fungal
infection, which is very common in infants and
young children caused by the yeast-like fungus
Candida albicans.

C. Albicans is a commensal of the oral cavity,
gastrointestinal tract and vagina.
 MOST COMMON CAUSE OF FUNGAL INFECTION

Potential Site for infection in disseminated systemic
candidiasis : GIT, Trachea, Lungs, Liver, Kidneys and CNS

may result in septicemia, meningitis, hepatospleenic disease,
and endocarditis
Diagnostic Test

The diagnosis of oral candidiasis is most frequently
made on the basis of clinical appearance along
with exfoliative cytology examination.
 This involves the Histological Examination of
intraoral scrapings which have been smeared
microscope glass slides.
 A 10% - 20% Potassium Hydroxide Preparation
("KOH prep") can be used for immediate
microscopic identification of yeast cell forms.
 Gram staining reveals Large gram-positive
yeast
Oral Candidiasis

Clinical Signs & Symptoms

Pseudomembrane that is a white nonadherent plaques on the buccal mucosa
and the palate over a erythematous base.


This membrane consists of desquamated
epithelial cells, fibrin, leukocytes, and fungal
mycelium that attaches it to the inflamed
epithelium.
Difficulty feeding with infants
Antifungal Agents: Treatment of Oral Thrush
Polyene Macrolide Antibiotics


Nystatin*
Amphotericin B
Azoles
 Imidazoles




Ketoconazole
Miconazole
Clotrimazole
Triazoles

Fluconazole
How would you give the Medication?

Keep in consideration the age and type of infection. For
infants antifungal agents administered



Topical antifungals are usually the drug of choice for
uncomplicated, localized candidiasis in patients with
normal immune function.


Oral Suspension
Topical gel/cream
Systemic antifungals are usually indicated in cases of
disseminated disease and/or in immunocompromised patients.
Duration of therapy: Medication should be continued for
at least 48 hours after the disappearance of clinical
signs of candidiasis along with complete healing and the
absence of mucosal erythema.
Mechanism of Action of
Antifungal Agents
Cell Wall & Membranous Components

Fungal cell wall consists largely of Chitin, a
polymer of N-acetylglucosamine, rather than
peptidoglycan.


Thus uneffected by antibiotics such as penicillin,
oxacillin, ampicillin, etc…
The fungal membrane consists of ergosterol
rather than cholesterol found in mammilian
membranes
Fungal Cell Wall
Polyene Macrolides
Azole Antifungals
Antifungal Agents
NYSTATIN(Mycostatin, Nilstat, Nystex)
Pharmacokinetics

Absorption insignificant in skin, GIT, or vagina

Administered topically or orally
MOA

Binds to ergosterol in cell membrane forming cytotoxic pores
Spectrum of activity

C. albucans
Indications

Mucocutaneous candidal infection. DOC for oral thrush
Contraindication

Documented hypersensitivity
Dosage
Adults: 400,000 – 600,000 U PO: swish and swallow 4-5 times/d
Dissolve 1-2 (200,000-400,000 U) troches in mouth 4-5 times/d
Pediatric: Infants- Apply 100,000 – 200,000 U oral suspension 3-5 times/d
Older children- administer as in adults
Precautions: No serious adverse effects; bitter taste, nausea, abdominal pain,
diarrhea, uticaria
AMPHOTERICIN B (Fungizone Oral Suspension)
Pharmacokinetics

Absorption insignificant in GIT

Administered topically or orally
MOA

Binds to ergosterol in cell membrane forming cytotoxic pores
Spectrum of activity

C. albucans
Indications

Mucocutaneous candidal infection
Contraindications

Documented Hypersensitivity
Dosage
Adult: 100-200 mg PO; swish and swallow qid
Pediatric: Apply 100 mg oral suspension to affected areas of the mouth
Interactions

unlikely with oral administration due to poor absorption; may increase
nephrotoxicity when used with aminoglycosides and possibly with
cephalosporins; may increase methotrexate toxicity
Precautions
Minimal Adverse effects expected with PO administration
CLOTRIMAZOLE (Mycelex Troches)
NOTE: Not enough studies have been done for children under 3 years of age, thus
NOT RECOMMENDED FOR USE IN THESE PATIENTS!!!
Pharmacokinetics

Topical or Oral Administration
MOA

Inhibits Ergosterol Synthesis
Spectrum of activity

Numerous candidal species& Dermatophytes
Indications

Oral Thrush, Vulvovaginal candidiasis, and Deratophytic Infections

Prophylaxis for immunosuppressed individuals: radioactive therapy, renal
transplant, etc…
Contraindication

Documented hypersensitivity
Dosage
Adult: 10 mg troche dissolved PO 5 times/d
Pediatric: Not Establish
Interactions: None Reported
Precautions

Decreased Liver Function
MICONAZOLE (Daktar Oral gel)
Pharmacokinetics

Administered Topically, IV, or Oral

Hepatic Metabolism
MOA

Inhibits Ergosterol Synthesis
Spectrum of activity

Numerous candidal species & Dermatophytes
Indications

Mucocutaneous candidal infection& Seborrheic Dermatitis
Contraindication

Those who are my develop hypersensitivity reaction to active ingredient Sodium
Sulfite Anhydrous

Pregnant patient
Dosage

Apply 25 mg to affected areas of mouth qid; Exact topical dose not yet estabilshed
Interactions

None Reported
Precautions

Chemical irritation

IV or Oral Administration: Blood dyscrasias, Hyponatremia, Anaphylactic reaction,
Dysrhythmias, and/or fever
FLUCONAZOLE (Diflucan)
Pharmacokinetics

IV or Oral Administration

Crosses the BBB *
MOA

Inhibits Ergosterol Synthesis
Spectrum of activity

Numerous candidal species

C. neopformans
Indications

Oral Thrush, Cyprococcal meningitis, Vaginal candidiasis, Prophylaxis for immunosuppressed individuals:
Bone marrow transplant and HIV Patients
Contraindications

Documented Hypersensitivity
Dosage
Adult: 200 mg PO qd on day 1; followed by 100 mg/d PO for 3-4 d; total 5 d should be adequate
Pediatric: 6 mg/kg/d PO qd
Interactions

Serum levels may increase with hydrocholothiazide

Levels may decrease with chronic coadministration of rifampin

Codministration may decrease phenytoin clearance

Effects of anticoagulants may increase with coadministration

Cyclosporine concentrations increases may occur when administered concurrently
Precautions

Rash, Cholestasis, Hepatitis, and Hepatic Failure and Death with underlying conditions (eg. AIDS,
malignancy) and taking multiple concomitant medications
KETOCONAZOLE
Pharmacokinetics
• Administered Topically or taken orally
• Hepatic Metabolism
MOA
• Inhibits Ergosterol Synthesis
Spectrum of activity
• Broad spectrum: Numerous candidal specie, Endemic mycoses (Blastomyces, Coccidiodes,
and Histoplasma), and Dermatophytes
Indications
• Mucocutaneous candidal infection
• Seborrheic Dermatitis
• Infections by thoses species listed above
Adverse Effects
• Very minimal side effects, local topical irritation
• Hypersensitivity Reaction
• Nausea and vomiting with oral administration
• Adrenal and Gonadal steroid synthesis inhibition
• Teratogenic (only with extreme orally administered doses)
Dosage for pediatric pt.
• Apply 2% Ketoconazole cream between meals for 14 days
Contraindication
• Those who are my develop hypersensitivity reaction to active ingredient Sodium Sulfite
Anhydrous
Advice to the parents/guardians

Candida albicans yeast is EVERYWHERE!!! Clean and sterilize
pacifiers, bottles, toys, etc., your baby will likely still be exposed to this
yeast. clean any objects that go into your child's mouth.

If your baby gets thrush over and over. It may be the bottle or pacifiers.

Breastfeeding mothers beware if their baby has thrush may get a yeast
infection on their breasts and nipples, causing pain while breastfeeding

In older children, especially if they haven't recently been on antibiotics
or steroids, thrush can be a sign of uncontrolled diabetes mellitus or
any immune system disorder.

Infants with thrush that doesn't go away or keeps coming back can also
be associated with immune system problems, especially if your infant
isn't gaining weight well or has other infections and medical problems.
THANK YOU
For Your Attention!!!!