Treatment of Ocular Fungal Infections With Oral Fluconazole

doi:10.1016/S0002-9394(14)71234-6

American Journal of Ophthalmology

Volume 119, Issue 4, April 1995, Pages 477-481

https://doi.org/10.1016/S0002-9394(14)71234-6 Get rights and content

Purpose

We treated five patients who had ocular fungal infections with oral fluconazole to determine its safety and effectiveness.

Methods

We reviewed the case histories of the five patients. One patient had coccidioidomycosis and four had endogenous Candida endophthalmitis.

Results

The intraocular fungal infection resolved in all patients.

Conclusion

Fluconazole appears to be a safe and effective antifungal agent that can be administered orally and may be a useful agent for treating some intraocular fungal infections.

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There are more references available in the full text version of this article.

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Anidulafungin versus fluconazole in the treatment of Candida albicans chorioretinitis
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Citation Excerpt :
Therapeutic intravitreal concentrations can only be achieved with much higher systemic doses than those usually employed in clinical practice.7,9,11 On the other hand, regular azole compound doses used in IC do achieve therapeutic intraocular concentrations to inhibit the growth of C. albicans.1,12,15 For this reason, we decided to change the antifungal systemic therapy in our patient.
Candida albicans chorioretinitis is the most common cause of endogenous fungal endophthalmitis. Echinocandins are recommended as first-line therapy in the treatment of invasive candidiasis (IC), but in clinically stable patients with IC and endophthalmitis caused by Candida species susceptible to azole compounds these are the first-line treatment due to their better intraocular penetration.
A 42-year-old woman admitted to hospital for duodenal perforation after gastrointestinal surgery and treated with broad-spectrum antibiotics developed C. albicans candidemia. According to protocol, an antifungal treatment with anidulafungin was given. The patient presented no visual symptoms but on routinary ophthalmoscopic examination multiple bilateral chorioretinal lesions were observed. Systemic therapy was changed to fluconazole, with good systemic and ocular results.
Azole compounds are the first-line therapy for endophthalmitis associated with candidemia. However, clinical guidelines often propose echinocandins as the first option for IC. In some cases, C. albicans chorioretinitis will require a change in the systemic treatment to assure better intraocular penetration. According to the current evidence and our own experience, routine funduscopy is not necessary in all IC patients. However, we do recommend fundus examination in patients with visual symptoms or those unable to report them (paediatric patients and patients with an altered level of consciousness), and in those who are being treated with echinocandins in monotherapy.
La coriorretinitis por Candida albicans es la forma más frecuente de endoftalmitis endógena fúngica. En la enfermedad invasora por Candida (EIC), las equinocandinas son la primera opción de tratamiento, pero en pacientes con EIC clínicamente estables, con endoftalmitis y con un aislamiento de Candida sin resistencia a los azoles, son estos últimos los antifúngicos de elección por su mejor penetración intraocular.
Se presenta el caso de una mujer de 42 años con perforación duodenal posquirúrgica, antibioterapia intravenosa de amplio espectro y candidemia por C. albicans bajo tratamiento con anidulafungina. Aunque no presenta alteraciones visuales, se realiza exploración rutinaria del fondo de ojo, donde se observan múltiples lesiones coriorretinianas bilaterales. Se cambia el tratamiento a fluconazol, con buena evolución sistémica y ocular.
Las guías clínicas indican un tratamiento empírico inicial con equinocandinas para tratar la EIC. En caso de presentar coriorretinitis por C. albicans multisensible es recomendable un cambio de tratamiento a azoles sistémico para asegurar una adecuada concentración antifúngica intraocular. Con la evidencia actual y en nuestra experiencia no es necesaria la exploración rutinaria del fondo de ojo en todos los pacientes con EIC. Esta puede reservarse a pacientes con síntomas visuales, a pacientes incapaces de referir de manera precoz cualquier síntoma (pacientes pediátricos o aquellos con el nivel de conciencia alterado), o a pacientes tratados exclusivamente con equinocandinas.
ESCMID guideline for the diagnosis and management of Candida diseases 2012: Non-neutropenic adult patients
2012, Clinical Microbiology and Infection
Citation Excerpt :
Successful use of fluconazole has been reported in case series, where it was used at doses varying from 100 to 400 mg for at least two and up to 8 weeks. A number of these patients were treated with concomitant systemic amphotericin B deoxycholate [122-125]. Overall fluconazole 400 mg alone appeared to be effective in less-advanced disease [126].
This part of the EFISG guidelines focuses on non-neutropenic adult patients. Only a few of the numerous recommendations can be summarized in the abstract. Prophylactic usage of fluconazole is supported in patients with recent abdominal surgery and recurrent gastrointestinal perforations or anastomotic leakages. Candida isolation from respiratory secretions alone should never prompt treatment. For the targeted initial treatment of candidaemia, echinocandins are strongly recommended while liposomal amphotericin B and voriconazole are supported with moderate, and fluconazole with marginal strength. Treatment duration for candidaemia should be a minimum of 14 days after the end of candidaemia, which can be determined by one blood culture per day until negativity. Switching to oral treatment after 10 days of intravenous therapy has been safe in stable patients with susceptible Candida species. In candidaemia, removal of indwelling catheters is strongly recommended. If catheters cannot be removed, lipid-based amphotericin B or echinocandins should be preferred over azoles. Transoesophageal echocardiography and fundoscopy should be performed to detect organ involvement. Native valve endocarditis requires surgery within a week, while in prosthetic valve endocarditis, earlier surgery may be beneficial. The antifungal regimen of choice is liposomal amphotericin B +/- flucytosine. In ocular candidiasis, liposomal amphotericin B +/- flucytosine is recommended when the susceptibility of the isolate is unknown, and in susceptible isolates, fluconazole and voriconazole are alternatives. Amphotericin B deoxycholate is not recommended for any indication due to severe side effects.
Endogenous endophthalmitis: Bacterial and fungal
2012, Retina Fifth Edition
Failure of echinocandin therapy in the treatment of Candida glabrata chorioretinitis
2012, American Journal of the Medical Sciences
Echinocandins are commonly used as initial empiric therapy in cases of moderate to severe invasive candidiasis. The authors demonstrate that caution should be exercised in applying this approach in certain clinical situations. A case of Candida glabrata fungemia and associated chorioretinitis that was clinically resistant to therapy with micafungin but appeared to resolve with amphotericin B is presented. The authors then briefly review current issues regarding the diagnosis and treatment of C glabrata chorioretinitis.
Development and Optimization of Hyaluronic Acid-Poloxamer In-Situ Gel Loaded with Voriconazole Cubosomes for Enhancement of Activity against Ocular Fungal Infection
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¹: Dr. Luttrull is in private practice in Ventura, California.

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Treatment of Ocular Fungal Infections With Oral Fluconazole

Purpose

Methods

Results

Conclusion

Mayo Clin Proc

Am J Ophthalmol

Infect Dis Clin North Am

Clinical pharmacokinetics of fluconazole

Clin Pharmacokinet

Ocular uptake of fluconazole following oral administration

Arch Ophthalmol