Pharmacology

Fluconazole

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Fluconazole (Diflucan) is an intravenous and oral antifungal medication that inhibits ergosterol synthesis (an important component of fungal cell membranes). As an intensivist, I most often use this medication to cover Candida albicans infections (especially symptomatic cystitis given fluconazole’s excellent urine penetration); however, it doesn’t cover C. krusei and has variable coverage of C. glabrata at higher doses. Fluconazole also has wonderful bioavailability compared to most other drugs in this class.

Oropharyngeal candidiasis (“thrush”) is the most common opportunistic infection in those with HIVs. Fluconazole has shown to be just as effective (and better tolerated) than topical antifungals when used for this specific indication. In those with persistent candidemia (remember, fungemia carries a high morbidity/mortality rate!!), I often times jump straight to echinocandins like micafungin or caspofungin (not to mention amphotericin B for overwhelming infections in critically ill patients).

As a cardiac anesthesiologist, I most often administer fluconazole as a prophylactic measure in patients receiving durable left ventricular assist devices (LVADs). The data on what constitutes the “best surgical prophylaxis” for LVAD implantation is all over the place, but do we know that a subset of these patients have recurrent driveline/pocket infections, and we really don’t want these to track back to the heart.

Drop me a comment with your experiences and questions!

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