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(A israelii most common also A naeslundn. A viscosus. A odontolyticus, A meyeri, A geiencsenae)

Cervicofacial, pulmonary, abdominal, cerebral. & rarely pericarditis (IDCP 12:233. 2004)

Classically abdominal aclino presents as inloiabdominal or pubic mass abscess, fistula Itacl (Dis Catvi Rectum 48:575, 2005) years alter surgery & may mimic cancer (World J Gaslto 11 1722. 2005). Fino needle aspuale ot ceivicolacial actino established dx in 15 pts in Spain JMed Oral Pal ol Oral Ciro Bucal 9 467. 2004)

Ampicillin 50 mg per kg per day IV times 4-6 wks. then 0 5 gm amoxicillin po til! OR Penicillin G 10-20 million units per day IV times 4-6 wks, then penicillin V 2-4 grn pet day po Duration individualized, esp with surgical dobulking. lolal duration 3-6 mos. usually adequate lor thoiacic & abdominal & 3-6 wks toi cervicofacial (CID 38 444. 2004).

Doxycycllne or ceftriaxone or clindamycin or erythromycin Chloramphenicol 12.5-15 mg pet kg IV/po q6h lias been recommended tor CNS infection in pen-allergic pts

Tuboovarlan abscesses may complicate lUDs. Removal ot IUD is primary rx With abscesses intlammalory mass or (istulao. surgery otten required While penicillin G and ampicillin IV have been effective, with homo IV therapy, agents given q24h eg. cetlnaxone. are more practical (CID 19:161. f994) Surgery may tie necessary loi hemoptysis (An Thot Surg 74 185. 2002)

Aspergillosis IA lumigalus most common, also A tlavus and others) (CID 30 696, 20001

Aspergillosis IA lumigalus most common, also A tlavus and others) (CID 30 696, 20001

1 aspergillosis (ABPA)

, wilti asthma & 115% wilh cystic fibrosis

Allergic bronchopulmonary

ABPA found in 1 -2% of pts wilti fCID 37 (Suppl 3):37. 2003] Clinical manifestations- wheezing, putmon ary Infiltiates. bronchiectasis & librosis Airway colonization assoc. with T blood eosinophils t seium IgE,1 spectlic serum antibodies Allergic fungal sinusitis relapsing chronic sinusitis, nasal polyps wilhoul bony invasion, asthma, eczema or allergic rhinitis. T IgE levels and isolation ol Aspeigillus sp or other demaliaceous sp (Allotnana, Cladosporium, etc)

Acute asthma attacks associated with ABPA Corticosteroids

Rx ol ABPA Itraconazole'

200 mg po q24h limesl 6 wks or longer (Allergy 60:1004. 2005)

In 2 PRCTs\ lira I number ol exacerbations requiring corticosteioids (p ■ 0 03), improved immunological markers (eosinophils in spulum & I arum IgE levels), & in 1 study improved lung tunction & exercise tolerance (NEJM 342.756, 2000: Cochrane Database Syst flev 3CD001108, 20041

Rx controversial: systemic cortico steroids + surgical debridement (80% respond but 2/3 relapse) (Otolaryn Head Neck Su/g 131.704. 2004)

For latluros try itra' 200 mg po bid Ilmes12 mos (CID 31: 203. 2000) Flucon nasal spiay benetited 12/16 pis (EOT/83:

In 1 report, fungal elements identilied by hislopalhology in up to 93% ot cases ot "chronic sinusitis" & in a DBPCT in 24 pts, intranasal amplio was assoc with a I In mucosal thickening ot 8.6% by CT scan vs Î ol 2 5% in placebo (LnlD 4:257. 2004) Conlioveisial aiea a (fungus bsll) (J Resp Dis 23:300.

Efficacy ol anliinicrobial agents not proven Itraconazole (|)o) benelll (oponed srvr.uli .11,' [J Am A::,:! : • "•". ' : >■ — '>

Voriconazole 6 nig pa kg IV ql2h on day 1. then eithet (4 mg per kg IVq!2h) or (200 mg po ql2h lor body weight >40 kg. but 100 mg po q12h tor body weight <40 kg) OR Lipid-based ampho B may be as effective and less nephiotoxic than standard ampho 6 but much more expensive (see footnote' for dosages). Some authorities now preler lipid-based ampho B over standard ampho B as initial rx (CID 32: 415. 2003) OR Ampho B (see footnote' page 76) Rapid increase lo 1 mg per ka (1-1 25 mg per kg it neutropenic) IV q24h Tola! dose of 2-2.5 gm tec. by some but data to support this lacking OR Combination rx: Vori On above dosages) - csspo (dosage t>e/ow) are cuuenlly preferred initial treatment in many bone marrcrw transplant units, esp in pts receiving high doses ot corticosteroids (Abstracts in Heme & One 8 11. 2005)

Post-transplantation and post-chemotherapy m neutropenic pis |PMN <500 per mm1) but may also present with neutrophil recovery (Mycopatho-logia 159:181. 2005) Most common pneumonia in tiansplanl recipienls Usually a lale (2100 days) complication in allogeneic bone mairow & liver Iransplanlation median survival 36 days, bul overall mortality rates vary from 78-94% iCID 36:46. 2003) May complicate COPD when coilicosteroids used (Clin Micro Inl 11 427. 2005)

Typical x-ray/CT lung lesions ¡halo sign, cavitation. or mycotic lung sequestration) have 90% positive predictive value tor invasive pulmonary aspergillosis in pts with hematologic malignancies (CID 31 859.2000)

An immunologic test thai detects circulating galactomannan is availablo tot dx ol invasive aspergillosis A incent article loviews the stiengths & weaknesses ol the lest ¡CID 41 (Suppl 6J .S38I, (continued on next page)

Oral solution preferred to tablets because of' absorption see Table f IS. page 83) PRCTs Prospective randomized controlled trials Dosages: ABLC 5 mg per kg por day IV over 2 hrs. ABCC 3-4 mg per kg pet day IV given as 1 mg pel kg pel hi liposomal Ampho B 3-5 mg per k

See page 2 lor abbreviations Alt dosage recommendations are lor adults (unless otherwise indicated) and assume norma) renal Lnclion

(continued on next page)

Aspef^ilbs rna^complicate pulmonary sequestration (Eur J Cardio Thor

Voriconazole n,-.ip --r-. ■,:tiv>:- ii-„in ampho B in randomized trial ol 277 rnimunosupptesseo pts with tPA, 53% responded vs 32% rx with ampho B Overall survival belter (71 vs 58%) (NEjM 347 406.2002) Appears particularly advantageous in cetebral aspergillosis (CID 39 603, 2004) & as salvage therapy in those with teliactory infection (Eur J Haematol 73 50. 2004) 40% ol 31 pts survived with vori alone. Von reputed satisfactory results in 11/20 pis with bone involvement (18 lot salvage), lollow-up average ol 3 mos (CID 40 1141, 2005)

Ampho B overall success rate 34-42% (CID 32 358. 2001) in pulmonary aspergillosis in pts rx ?14 days. Success dependent on underlying disease 83% tieatlAidnuy transplants, 54% neutropenic leukemia pts. 33% bone marrow transplant. 20% Irvet transplant (CID 23 608. 1996) 44% ot 398 pts receiving ampho B lipid complex (ABLC) were cuied oi improved & 21% stabilized, most had tailed lo respond to prior antitungal rx (CID 40.S392. 2005) A. terreus Infections particularly resistant to ampho B: in 83 cases. 73.4% mortality with ampho B rx vs 55.8% with voriconazole rx (p <0.01) (CID 39 192. 2004) Use vori!

Caspofungin: Among 83 pts with IPA included in Ihe primary (MITT) analysis. 37 (45%) had turntable response following salvage rx with caspo monotherapy In pts receiving >7 days ol caspo monotherapy, 56% (37/66) responded favorably (CID 39 (563.2004) Response in compassionate use program 44% (J Inl 50:196.2005) Minimal toxicity reported (Transpi/rrfDrs '25. 2002)

Mlcstungin: 57% clinical response in an open-label study ol "deep-seated" intections (Scand J Inl Drs 36 372. 2004)

Combination therapy: To date no controlled patient trials, and they are needed (CID 39 803. 2004) No antagonism between Iriazoles (von & itra), echinocandins (caspo). & ampho B Synergy (continued on next page)

I per day tV given over 1 -2 hrs

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