. . . . . . . . . . . . . . "4.2 \tD\u00E1vkov\u00E1n\u00ED a zp\u016Fsob pod\u00E1n\u00ED"@cs . . . . . . . . . . . "004.002" . . . . . . . "Denn\u00ED d\u00E1vku flukonazolu vol\u00EDme podle druhu a z\u00E1va\u017Enosti mykotick\u00E9 infekce. Ve v\u011Bt\u0161in\u011B p\u0159\u00EDpad\u016F vagin\u00E1ln\u00ED kandid\u00F3zy je dostate\u010Dn\u00E1 jednor\u00E1zov\u00E1 d\u00E1vka. Pokud charakter infekce vy\u017Eaduje opakovan\u00E9 pod\u00E1n\u00ED, pak mus\u00ED l\u00E9\u010Dba pokra\u010Dovat a\u017E do vymizen\u00ED klinick\u00FDch a laboratorn\u00EDch zn\u00E1mek aktivity onemocn\u011Bn\u00ED. P\u0159i p\u0159ed\u010Dasn\u00E9m ukon\u010Den\u00ED l\u00E9\u010Dby m\u016F\u017Ee doj\u00EDt k relapsu infekce. U pacient\u016F s AIDS, s kryptokokovou meningitidou nebo recidivuj\u00EDc\u00ED orofarynge\u00E1ln\u00ED kandid\u00F3zou je k\u00A0zabr\u00E1n\u011Bn\u00ED relapsu obvykle nutn\u00E9 pokra\u010Dovat udr\u017Eovac\u00ED terapi\u00ED.\nU\u017Eit\u00ED u dosp\u011Bl\u00FDch\n1. U kryptokokov\u00E9 meningitidy, ale i v jin\u00FDch lokalizac\u00EDch kryptokokov\u00E9 infekce je obvykl\u00E1 d\u00E1vka 400\u00A0mg prvn\u00ED den a d\u00E1le 200 \u2013 400\u00A0mg denn\u011B v jedn\u00E9 denn\u00ED d\u00E1vce. U \u017Eivot ohro\u017Euj\u00EDc\u00EDch infekc\u00ED zp\u016Fsoben\u00FDch Cryptococcus neoformans m\u016F\u017Ee b\u00FDt d\u00E1vka zv\u00FD\u0161ena a\u017E na 800\u00A0mg 1x denn\u011B. Trv\u00E1n\u00ED l\u00E9\u010Dby kryptokokov\u00FDch infekc\u00ED z\u00E1vis\u00ED na klinick\u00E9 a mykologick\u00E9 odezv\u011B, ale u kryptokokov\u00E9 meningitidy trv\u00E1 alespo\u0148 6 - 8 t\u00FDdn\u016F.\nK prevenci relapsu kryptokokov\u00E9 meningitidy je u pacient\u016F s AIDS - po dokon\u010Den\u00ED \u00FAvodn\u00ED \u00FAto\u010Dn\u00E9 terapie - vhodn\u00E9 trvale pod\u00E1vat flukonazol v denn\u00ED d\u00E1vce 200\u00A0mg.\n2. U kandid\u00E9mie, diseminovan\u00E9 kandid\u00F3zy a ostatn\u00EDch invazivn\u00EDch kandidov\u00FDch infekc\u00ED se obvykle prvn\u00ED den pod\u00E1v\u00E1 400\u00A0mg a d\u00E1le 200\u00A0mg denn\u011B. V z\u00E1vislosti na klinick\u00E9 odpov\u011Bdi m\u016F\u017Ee b\u00FDt denn\u00ED d\u00E1vka zv\u00FD\u0161ena na 400\u00A0mg. U \u017Eivot ohro\u017Euj\u00EDc\u00EDch infekc\u00ED zp\u016Fsoben\u00FDch rodem Candida m\u016F\u017Ee b\u00FDt d\u00E1vka zv\u00FD\u0161ena a\u017E na 800\u00A0mg 1x denn\u011B. Na klinick\u00E9 odezv\u011B z\u00E1vis\u00ED i d\u00E9lka l\u00E9\u010Dby.\n3. V p\u0159\u00EDpad\u011B orofarynge\u00E1ln\u00ED kandid\u00F3zy se obvykle pod\u00E1v\u00E1 50 \u2013 100\u00A0mg v jedn\u00E9 denn\u00ED d\u00E1vce po dobu 7 - 14 dn\u016F. U pacient\u016F s t\u011B\u017Ek\u00FDm posti\u017Een\u00EDm imunity lze v p\u0159\u00EDpad\u011B pot\u0159eby pokra\u010Dovat v terapii po del\u0161\u00ED dobu. U atrofick\u00E9 or\u00E1ln\u00ED kandid\u00F3zy vznikl\u00E9 ve spojitosti s um\u011Bl\u00FDm chrupem se obvykle pod\u00E1v\u00E1 50\u00A0mg jednou denn\u011B po dobu 14 dn\u016F. Zubn\u00ED n\u00E1hradu sou\u010Dasn\u011B dezinfikujeme lok\u00E1ln\u00EDmi antiseptiky.\nU ostatn\u00EDch kandidov\u00FDch slizni\u010Dn\u00EDch infekc\u00ED (s v\u00FDjimkou kandid\u00F3zy genit\u00E1lu - viz n\u00ED\u017Ee), nap\u0159. ezofagitidy, neinvazivn\u00EDch bronchopulmon\u00E1ln\u00EDch infekc\u00ED, kandidurie, mukokut\u00E1nn\u00EDch kandid\u00F3z atd. je obvykle \u00FA\u010Dinn\u00E1 denn\u00ED d\u00E1vka 50 \u2013 100\u00A0mg pod\u00E1van\u00E1 14 a\u017E 30 dn\u016F.\nU nemocn\u00FDch s AIDS je mo\u017En\u00E9 po dokon\u010Den\u00ED \u00FAto\u010Dn\u00E9 f\u00E1ze l\u00E9\u010Dby zabr\u00E1nit relapsu orofarynge\u00E1ln\u00ED kandid\u00F3zy d\u00E1vkou 150\u00A0mg jedenkr\u00E1t t\u00FDdn\u011B.\n4. P\u0159i l\u00E9\u010Db\u011B vagin\u00E1ln\u00ED kandid\u00F3zy pod\u00E1v\u00E1me 150\u00A0mg flukonazolu v jedn\u00E9 peror\u00E1ln\u00ED d\u00E1vce.\nKe sn\u00ED\u017Een\u00ED v\u00FDskytu rekurentn\u00ED vagin\u00E1ln\u00ED kandid\u00F3zy je mo\u017En\u00E9 pod\u00E1vat 150\u00A0mg jedenkr\u00E1t m\u011Bs\u00ED\u010Dn\u011B. D\u00E9lka l\u00E9\u010Dby je individu\u00E1ln\u00ED, pohybuje se v rozmez\u00ED 4 - 12 m\u011Bs\u00EDc\u016F. U n\u011Bkter\u00FDch pacientek je t\u0159eba doporu\u010Dit \u010Dast\u011Bj\u0161\u00ED d\u00E1vkov\u00E1n\u00ED.\nJednor\u00E1zovou d\u00E1vku 150\u00A0mg pou\u017E\u00EDv\u00E1me i pro l\u00E9\u010Dbu kandidov\u00E9 balanitidy.\n5. Pro prevenci kandid\u00F3zy se doporu\u010Den\u00E9 d\u00E1vkov\u00E1n\u00ED pohybuje v z\u00E1vislosti na individu\u00E1ln\u00EDm riziku vzniku mykotick\u00E9 infekce, a to od 50 do 400\u00A0mg denn\u011B. Pacient\u016Fm s vysok\u00FDm rizikem syst\u00E9mov\u00E9 infekce, nap\u0159. t\u011Bm, u kter\u00FDch lze p\u0159edpokl\u00E1dat hlubokou \u010Di dlouhodobou neutropenii, doporu\u010Dujeme pod\u00E1vat 400\u00A0mg denn\u011B v jedn\u00E9 d\u00E1vce. Flukonazol je l\u00E9pe za\u010D\u00EDt pod\u00E1vat n\u011Bkolik dn\u016F p\u0159ed o\u010Dek\u00E1van\u00FDm n\u00E1stupem neutropenie a v terapii pokra\u010Dovat je\u0161t\u011B dal\u0161\u00EDch 7 dn\u00ED potom, co po\u010Det neutrofil\u016F p\u0159es\u00E1hl 1000/mm3.\n6. Pro ko\u017En\u00ED infekce, v\u010Detn\u011B tinea pedis, corporis, cruris a infekce kandidov\u00E9 je doporu\u010Den\u00E9 d\u00E1vkov\u00E1n\u00ED 150\u00A0mg t\u00FDdn\u011B nebo 50\u00A0mg denn\u011B. L\u00E9\u010Dba obvykle trv\u00E1 dva a\u017E \u010Dty\u0159i t\u00FDdny, ale tinea pedis m\u016F\u017Ee vy\u017Eadovat a\u017E \u0161estit\u00FDdenn\u00ED l\u00E9\u010Dbu.\nU tinea versicolor je doporu\u010Den\u00E1 d\u00E1vka 300\u00A0mg jedenkr\u00E1t t\u00FDdn\u011B po dobu 2 t\u00FDdn\u016F. U n\u011Bkter\u00FDch nemocn\u00FDch je n\u011Bkdy nutn\u00E1 je\u0161t\u011B d\u00E1vka 300\u00A0mg i v t\u0159et\u00EDm t\u00FDdnu, zat\u00EDmco u jin\u00FDch m\u016F\u017Ee sta\u010Dit jen jednor\u00E1zov\u00E9 pod\u00E1n\u00ED d\u00E1vky 300 \u2013 400\u00A0mg. Je tak\u00E9 mo\u017En\u00E9 pou\u017E\u00EDt alternativn\u00ED d\u00E1vkov\u00E1n\u00ED 50\u00A0mg jedenkr\u00E1t denn\u011B po dobu 2 - 4 t\u00FDdn\u016F.\nDoporu\u010Den\u00E1 d\u00E1vka k l\u00E9\u010Db\u011B tinea unguium je 150\u00A0mg jedenkr\u00E1t t\u00FDdn\u011B. L\u00E9\u010Dba by m\u011Bla pokra\u010Dovat a\u017E do doby, kdy je nehet po\u0161kozen\u00FD infekc\u00ED nahrazen nov\u00FDm. To obvykle trv\u00E1 3-6 m\u011Bs\u00EDc\u016F a u neht\u016F palc\u016F 6-12 m\u011Bs\u00EDc\u016F. R\u016Fst neht\u016F je ale velmi individu\u00E1ln\u00ED a z\u00E1le\u017E\u00ED i na v\u011Bku pacienta. I po \u00FAsp\u011B\u0161n\u00E9 l\u00E9\u010Db\u011B chronick\u00E9 infekce nehtu m\u016F\u017Ee n\u011Bkdy p\u0159etrv\u00E1vat jeho defigurace.\n7. U syst\u00E9mov\u00FDch endemick\u00FDch myk\u00F3z je nutn\u00E1 d\u00E1vka 200 \u2013 400\u00A0mg denn\u011B pod\u00E1van\u00E1 a\u017E po dobu dvou let. D\u00E9lka l\u00E9\u010Dby je individu\u00E1ln\u00ED, pr\u016Fm\u011Brn\u011B 11 - 24 m\u011Bs\u00EDc\u016F u kokcidiomyk\u00F3zy, 2 - 17 m\u011Bs\u00EDc\u016F u parakokcidiomyk\u00F3zy, 1 - 16 m\u011Bs\u00EDc\u016F u sporotrich\u00F3zy a 3 - 17 m\u011Bs\u00EDc\u016F u histoplazm\u00F3zy.\nU\u017Eit\u00ED u d\u011Bt\u00ED\nTrv\u00E1n\u00ED l\u00E9\u010Dby, tak jako u obdobn\u00FDch infekc\u00ED u dosp\u011Bl\u00FDch, z\u00E1vis\u00ED na klinick\u00E9 a mykologick\u00E9 odezv\u011B.. Flukonazol se pod\u00E1v\u00E1 v jedn\u00E9 denn\u00ED d\u00E1vce ka\u017Ed\u00FD den.\nD\u011Bti se sn\u00ED\u017Eenou ren\u00E1ln\u00ED funkc\u00ED \u2013 viz d\u00E1vkov\u00E1n\u00ED v\u00A0bod\u011B \u201EU\u017Eit\u00ED u pacient\u016F s\u00A0poruchou ren\u00E1ln\u00ED funkce\u201C\nU\u017Eit\u00ED u d\u011Bt\u00ED ve v\u011Bku 4 t\u00FDdn\u016F a v\u00EDce\nDoporu\u010Den\u00E9 d\u00E1vkov\u00E1n\u00ED flukonazolu u slizni\u010Dn\u00ED kandid\u00F3zy je 3\u00A0mg/kg/den. Prvn\u00ED den l\u00E9\u010Dby je vhodn\u00E9 podat nasycovac\u00ED d\u00E1vku 6\u00A0mg/kg, \u010D\u00EDm\u017E se rychleji dos\u00E1hne ust\u00E1len\u00E9 hladiny.\nL\u00E9\u010Dba syst\u00E9mov\u00E9 kandid\u00F3zy a kryptokokov\u00FDch infekc\u00ED vy\u017Eaduje d\u00E1vku 6 \u2013 12\u00A0mg/kg/den, v z\u00E1vislosti na celkov\u00E9 z\u00E1va\u017Enosti onemocn\u011Bn\u00ED.\nU imunitn\u011B oslaben\u00FDch pacient\u016F s rizikem neutropenie po chemoterapii nebo po radia\u010Dn\u00ED l\u00E9\u010Db\u011B je jako prevenci mykotick\u00FDch infekc\u00ED vhodn\u00E9 pod\u00E1vat 3 \u2013 12\u00A0mg/kg denn\u011B, podle rozsahu a d\u00E9lky trv\u00E1n\u00ED indukovan\u00E9 neutropenie (viz U\u017Eit\u00ED u dosp\u011Bl\u00FDch).\nMaxim\u00E1ln\u00ED d\u00E1vka 400mg denn\u011B nesm\u00ED b\u00FDt u d\u011Bt\u00ED p\u0159ekro\u010Dena.\nU\u017Eit\u00ED u d\u011Bt\u00ED do 4 t\u00FDdn\u016F v\u011Bku\nU novorozenc\u016F prob\u00EDh\u00E1 vylu\u010Dov\u00E1n\u00ED flukonazolu pomalu. V prvn\u00EDch dvou t\u00FDdnech \u017Eivota je d\u00E1vkov\u00E1n\u00ED l\u00E9ku v mg/kg shodn\u00E9 jako u star\u0161\u00EDch d\u011Bt\u00ED, av\u0161ak d\u00E1vky pod\u00E1v\u00E1me ka\u017Ed\u00FDch 72 hodin. V pr\u016Fb\u011Bhu 3. \u2013 4. t\u00FDdne \u017Eivota pod\u00E1v\u00E1me stejnou d\u00E1vku ka\u017Ed\u00FDch 48 hodin.\nFarmakokinetick\u00E9 \u00FAdaje podporuj\u00EDc\u00ED toto d\u00E1vkov\u00E1n\u00ED pro novorozence viz bod 5.2. \u2013 Farmakokinetick\u00E9 vlastnosti.\nMaxim\u00E1ln\u00ED d\u00E1vka 12mg/kg ka\u017Ed\u00FDch 72 hodin nesm\u00ED b\u00FDt p\u0159ekro\u010Dena u d\u011Bt\u00ED v prvn\u00EDch dvou t\u00FDdnech \u017Eivota. U d\u011Bt\u00ED mezi 3. a 4. t\u00FDdnem \u017Eivota nesm\u00ED b\u00FDt p\u0159ekro\u010Dena d\u00E1vka 12mg/kg ka\u017Ed\u00FDch 48 hodin.\nFarmakokinetick\u00E1 studie flukonazolu nebyla u d\u011Bt\u00ED s ren\u00E1ln\u00ED insuficienc\u00ED prov\u00E1d\u011Bna.\nU\u017Eit\u00ED u star\u0161\u00EDch pacient\u016F \nNejsou - li zn\u00E1mky po\u0161kozen\u00ED ledvin, plat\u00ED b\u011B\u017En\u00FD zp\u016Fsob d\u00E1vkov\u00E1n\u00ED. U pacient\u016F s ren\u00E1ln\u00ED poruchou (clearance kreatininu ( 50\u00A0ml/min) d\u00E1vkovac\u00ED sch\u00E9ma upravujeme, jak je pops\u00E1no n\u00ED\u017Ee.\nU\u017Eit\u00ED u pacient\u016F s poruchou ren\u00E1ln\u00ED funkce\nFlukonazol se v nezm\u011Bn\u011Bn\u00E9 form\u011B vylu\u010Duje p\u0159ev\u00E1\u017En\u011B mo\u010D\u00ED. D\u00E1vku p\u0159i jednor\u00E1zov\u00E9 l\u00E9\u010Db\u011B nen\u00ED t\u0159eba upravovat. Pacient\u016Fm (v\u010Detn\u011B d\u011Bt\u00ED) s poruchou ren\u00E1ln\u00EDch funkc\u00ED l\u00E9\u010Den\u00FDch opakovan\u00FDmi d\u00E1vkami pod\u00E1v\u00E1me po\u010D\u00E1te\u010Dn\u00ED nasycovac\u00ED d\u00E1vku 50 \u2013 400\u00A0mg a pot\u00E9 denn\u00ED d\u00E1vku (v z\u00E1vislosti na indikaci) uprav\u00EDme podle n\u00E1sleduj\u00EDc\u00ED tabulky:\n\tClearance kreatininu\n[ml/min] [ml/sec]\n\tProcento doporu\u010Den\u00E9 d\u00E1vky\n\t( 50 > 0,8\n\t100 %\n\t( 50 ( bez dial\u00FDzy) 0,2 - 0,8\n\t50 %\n\tPravideln\u00E1 dial\u00FDza\n\t100 % po ka\u017Ed\u00E9 dial\u00FDze\nZp\u016Fsob pod\u00E1n\u00ED\nFlukonazol lze pod\u00E1vat bu\u010F peror\u00E1ln\u011B nebo formou intraven\u00F3zn\u00ED infuze nejv\u00FD\u0161e rychlost\u00ED 10\u00A0ml/min. Cesta pod\u00E1n\u00ED z\u00E1vis\u00ED na klinick\u00E9m stavu pacienta. P\u0159i p\u0159echodu z intraven\u00F3zn\u00EDho na peror\u00E1ln\u00ED pod\u00E1n\u00ED (a naopak) se denn\u00ED d\u00E1vkov\u00E1n\u00ED nemus\u00ED m\u011Bnit. Infuze flukonazolu je p\u0159ipravena v 0,9\u00A0% roztoku chloridu sodn\u00E9ho; na 200\u00A0mg (100\u00A0ml lahvi\u010Dka) p\u0159ipad\u00E1 po 15\u00A0mmol Na+ a Cl-. Vzhledem k tomu, \u017Ee se flukonazol dod\u00E1v\u00E1 ve fyziologick\u00E9m roztoku, je t\u0159eba u pacient\u016F vy\u017Eaduj\u00EDc\u00EDch omezen\u00ED p\u0159\u00EDjmu sod\u00EDku \u010Di tekutin v\u011Bnovat pozornost jejich celkov\u011B podan\u00E9mu mno\u017Estv\u00ED.\n"@cs . . . .