title: Invasive mycoses: strategies for effective management.
abstract: Effective management of invasive fungal infections (IFIs) depends on early individualized therapy that optimizes efficacy and safety. Considering the negative consequences of IFI, for some high-risk patients the potential benefits of prophylactic therapy may outweigh the risks. When using a prophylactic, empiric, or preemptive therapeutic approach, clinicians must take into account the local epidemiology, spectrum of activity, pharmacokinetic and pharmacodynamic parameters, and safety profile of different antifungal agents, together with unique host-related factors that may affect antifungal efficacy or safety. Therapeutic drug monitoring is increasingly recognized as important or necessary when employing lipophilic triazoles (itraconazole, voriconazole, posaconazole) or flucytosine. Because early diagnostics remain limited for uncommon, yet emerging opportunistic molds (e.g., Mucorales), and treatment delay is associated with increased mortality, early effective management often depends on a high index of suspicion, taking into account predisposing factors, host cues favoring mucormycosis, and local epidemiology. Antifungal options for mucormycosis are limited, and optimal management depends on a multimodal approach that includes early diagnosis/clinical suspicion, correction of underlying predisposing factors, radical debridement of affected tissues, and extended antifungal therapy. This article discusses strategies for the effective management of invasive mycoses, with a particular focus on antifungal hepatotoxicity.
authors.affiliation: Division of Internal Medicine, Department of Infectious Diseases Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA. dkontoyi@mdanderson.org
authors.forename: Dimitrios P
authors.initials: DP
authors.lastname: Kontoyiannis
mesh_terms: D000328:Adult; D000410:Alanine Transaminase / Q000097:blood; D000469:Alkaline Phosphatase / Q000097:blood; D000935:Antifungal Agents / Q000008:administration & dosage* / Q000009:adverse effects* / Q000493:pharmacokinetics; D000970:Antineoplastic Agents / Q000008:administration & dosage / Q000009:adverse effects; D001219:Aspartate Aminotransferases / Q000097:blood; D001228:Aspergillosis / Q000188:drug therapy; D001663:Bilirubin / Q000097:blood; D015415:Biomarkers / Q000097:blood; D016903:Drug Monitoring; D054714:Echinocandins / Q000008:administration & dosage / Q000009:adverse effects; D005260:Female; D005437:Flucytosine / Q000008:administration & dosage / Q000009:adverse effects; D006801:Humans; D016867:Immunocompromised Host; D007938:Leukemia / Q000188:drug therapy; D008099:Liver / Q000187:drug effects* / Q000378:metabolism*; D008111:Liver Function Tests / Q000592:standards; D008297:Male; D008875:Middle Aged; D009091:Mucormycosis / Q000188:drug therapy / Q000601:surgery; D009181:Mycoses / Q000188:drug therapy* / Q000378:metabolism / Q000382:microbiology* / Q000601:surgery; D009190:Myelodysplastic Syndromes / Q000188:drug therapy; D009894:Opportunistic Infections / Q000188:drug therapy; D011014:Pneumonia / Q000188:drug therapy / Q000382:microbiology; D012307:Risk Factors; D014230:Triazoles / Q000008:administration & dosage / Q000009:adverse effects
chemical_list: D000935:Antifungal Agents; D000970:Antineoplastic Agents; D015415:Biomarkers; D054714:Echinocandins; D014230:Triazoles; D005437:Flucytosine; D001219:Aspartate Aminotransferases; D000410:Alanine Transaminase; D000469:Alkaline Phosphatase; D001663:Bilirubin