Miscellaneous Topical Antifungal Agents

Ciclopirox olamine (Loprox) is a pyridone derivative available for the treatment of cutaneous dermatophyte infections, cutaneous C. albicans infections, and tinea versicolor caused by Malassezia furfur. It interferes with fungal growth by inhibiting macromolecule synthesis.

Tolnaftate (Tinactin, others) is a nonprescription an-tifungal agent effective in the topical treatment of der-matophyte infections and tinea. The mechanism of action is unknown.

Other older, less effective topical antifungal agents still available include undecylenic acid (Desenex, others). Used in the treatment of topical dermatophytes, undecylenic acid is fungistatic, requires prolonged administration, and is associated with a high relapse rate. Desenex, containing 5% undecylenic acid and 20% zinc undecylenate, is effective in the prevention of recurrent tinea pedis.

^Study Questions

1. A 65-year-old man with acute leukemia recently underwent induction chemotherapy and subsequently developed neutropenia and fever (with no source of fever identified). Fever persisted despite the use of empirical antibacterial therapy, and amphotericin B has been prescribed for possible fungal sepsis. Which laboratory test is LEAST helpful in monitoring for toxicities associated with amphotericin B?

(A) Liver function tests

(B) Serum potassium

(C) Serum magnesium

(D) Serum blood urea nitrogen and creatinine

(E) Hemoglobin and hematocrit

2. A 55-year-old obese woman with adult-onset diabetes mellitus has been receiving amoxicillin for treatment of an acute exacerbation of chronic bronchitis. After a week of therapy, the patient develops dysuria and increased urinary frequency. Urinalysis shows 10 to 50 white blood cells per high-power field, and Gram stain of urine shows many budding yeasts. Which antifungal agent would be best in treating this patient for Candida cystitis?

(A) Oral ketoconazole

(B) Oral fluconazole

(C) Topical clotrimazole

(D) Oral 5-flucytosine

(E) Oral itraconazole

3. A 43-year-old woman recently underwent allo-geneic bone marrow transplantation after chemotherapy failed in the treatment of metastatic breast carcinoma. The patient has had a stormy hospital course after her transplant, with respiratory failure requiring mechanical ventilation. A month into her hospitalization, surveillance sputum cultures reveal Aspergillus fumigatus, and a new infiltrate appears on her chest radiograph. Which antifungal agent is recommended for the treatment of invasive pulmonary aspergillosis in this patient?

(A) Fluconazole

(B) Amphotericin B

(C) Amphotericin B with 5-flucytosine

(D) Capsofungin

(E) Itraconazole

4. A 57-year-old man with extensive onychomycosis (fungal toenail infection) asks you for an evaluation. He requests a prescription for itraconazole for treatment of this problem after seeing a television advertisement for this drug. He has chronic heartburn attributed to gastroesophageal reflux disease and is treated with the proton pump inhibitor omeprazole. He is taking lovastatin for treatment of hyperlipidemia. Three years ago he underwent cadaveric renal transplantation for end-stage kidney disease secondary to polycystic kidney disease and is taking cyclosporin to prevent transplant rejection. In prescribing itraconazole for this patient, what adjustments in his medication regimen do you recommend?

(A) Discontinue omeprazole and substitute the H2 blocker ranitidine.

(B) Discontinue omeprazole and substitute liquid antacids.

(C) Discontinue omeprazole.

(D) Continue lovastatin.

(E) Increase cyclosporin dosing.

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