What treatment options are suggested for a patient with persistent cough, history of allergy-induced asthma, and bronchoscopy cultures showing heavy growth of Staphylococcus aureus and Candida albicans?

From the Guidelines

For a patient with persistent cough, allergy-induced asthma, and bronchoscopy cultures showing heavy growth of Staphylococcus aureus and Candida albicans, I recommend a multi-faceted treatment approach. The patient should be started on an antistaphylococcal antibiotic such as trimethoprim-sulfamethoxazole (Bactrim) 1 double-strength tablet twice daily for 10-14 days, or cephalexin 500mg four times daily for the same duration to address the S. aureus infection, as suggested by the Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults 1. For the Candida albicans, fluconazole 200mg on day one followed by 100mg daily for 7-14 days is appropriate. Concurrently, the patient's underlying asthma should be optimized with a combination inhaled corticosteroid and long-acting beta-agonist such as fluticasone/salmeterol (Advair) twice daily, plus a rescue inhaler like albuterol as needed, as recommended by the British Thoracic Society guideline for bronchiectasis in adults 1 and the guidelines for the management of adult lower respiratory tract infections 1. A short course of oral prednisone (40mg daily for 5 days, tapering not required for short course) may help reduce airway inflammation, as suggested by the diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines 1. The patient should also use a spacer with inhalers if not already doing so, maintain good hydration, and consider saline nasal irrigation if upper airway symptoms are present. This comprehensive approach addresses both the infectious components and the underlying asthma, which may be exacerbated by the infections. The presence of both pathogens suggests possible immune dysfunction or structural airway issues that may require further evaluation after this initial treatment course, as discussed in the managing chronic cough due to asthma and NAEB in adults and adolescents: CHEST guideline and expert panel report 1.

Some key points to consider in the treatment approach include:

• The importance of addressing both the S. aureus and Candida albicans infections simultaneously
• The need to optimize the patient's underlying asthma management to reduce airway inflammation and prevent exacerbations
• The potential for immune dysfunction or structural airway issues that may require further evaluation and treatment
• The importance of maintaining good hydration and considering saline nasal irrigation to help manage upper airway symptoms.

Overall, the treatment approach should prioritize the patient's morbidity, mortality, and quality of life, and be guided by the most recent and highest-quality evidence available, as discussed in the provided studies 1.

From the FDA Drug Label

Fluconazole tablets are indicated for the treatment of: ... Oropharyngeal and esophageal candidiasis ... systemic Candida infections including candidemia, disseminated candidiasis, and pneumonia. Specimens for fungal culture and other relevant laboratory studies (serology, histopathology) should be obtained prior to therapy to isolate and identify causative organisms Therapy may be instituted before the results of the cultures and other laboratory studies are known; however, once these results become available, anti-infective therapy should be adjusted accordingly.

The patient has a heavy growth of Candida albicans and Staphylococcus aureus. For the Candida albicans infection, treatment with fluconazole is suggested, as it is indicated for the treatment of systemic Candida infections. However, for Staphylococcus aureus, the provided drug label does not offer any treatment options.

• Fluconazole may be considered for the treatment of Candida infection.
• Treatment for Staphylococcus aureus is not mentioned in the provided drug label 2.

From the Research

Treatment Options for Persistent Cough with Staphylococcus aureus and Candida albicans Infection

• The patient's condition, with a history of allergy-induced asthma and bronchoscopy cultures showing heavy growth of Staphylococcus aureus and Candida albicans, suggests a complex infection requiring targeted treatment.
• For Candida albicans infection, fluconazole has been shown to be an effective treatment option 3, 4. The dose and duration of treatment may vary depending on the severity of the infection and the patient's response.
• In cases where Staphylococcus aureus and Candida albicans co-infect, the treatment approach may need to consider the synergistic effects of these pathogens 5. The use of antimicrobial agents that can target both pathogens, such as plumbagin, may be beneficial 6.
• Plumbagin, a naturally occurring naphthoquinone, has been shown to have antimicrobial activity against both Staphylococcus aureus and Candida albicans, with a minimum inhibitory concentration of 5μg/ml 6.
• In addition to antimicrobial treatment, infection control measures, such as those outlined in 7, should be implemented to prevent the transmission of infection and ensure a safe environment for the patient.

Considerations for Treatment

• The patient's history of allergy-induced asthma should be taken into account when selecting treatment options, and any potential interactions between asthma medications and antimicrobial agents should be considered.
• The use of prophylactic antibiotics, as mentioned in 7, may be considered in certain cases, but this should be determined on a case-by-case basis.
• Regular monitoring of the patient's condition, including follow-up bronchoscopy and culture results, is essential to assess the effectiveness of treatment and make any necessary adjustments.