33.王先生67歲，7年前腎臟移植，長期服用cyclosporine。2週前不明原因發燒，使用ceftriaxone及 imipenem/cilastatin治療無效。血液培養出Candida tropicalis，為保護其腎臟，下列何者為治療首選？
(A)vancomycin
(B)amphotericin B（liposomal）
(C)ketoconazole
(D)acyclovir

取自：https://www.google.com.tw/url?q=https://meddataspeaks.wordpress.com/2015/08/26/臨床藥學-不同candida-念珠菌屬感染的抗黴菌藥選擇/amp/

且Amphotericin B liposomal劑型較不傷腎

補充樓上 根據仿單和衛服部公告，口服ketoconazole沒有腎毒性問題喔，主要是"治療效益未大於發生肝損傷之風險"，故停止販售該藥品口服劑型！

來源：含ketoconazole成分口服劑型之抗真菌藥品，食品藥物管理署（以下簡稱食藥署）完成再評估，認為該成分之口服劑型藥品發生肝毒性之嚴重程度及發生率較其他同類抗黴菌藥品為高，並具有嚴重且複雜之藥物交互作用及心律異常（心臟QT間隔延長）風險，考量該藥品於我國主要為基層診所使用，不易有效監控及追蹤不良反應之發生，且目前已有其他更安全之藥品可供替代，對於局部感染之病人，仍保留該成分外用劑型藥品可供使用。含該成分口服劑型藥品待行政程序完成後，將於104年1月1日下市（廢止藥品許可證），倘醫療人員仍有其他必要之治療需求，可透過專案進口方式向食藥署申請。

ref:https://www.mohw.gov.tw/cp-3207-21330-1.html

ketoconazole肝腎毒性大，口服已經撤銷許可證了

因為副作用的關係，所以不當作黴菌治療的首選喔~

In August 2013, the FDA announced that clinicians should no longer prescribe ketoconazole (Nizoral, Janssen Pharmaceuticals) tablets as a first-line therapy for any fungal infection, including Candida and dermatophyte infections, because of the risk for severe liver injury, adrenal insufficiency, and adverse drug interactions. The FDA also cautioned that ketoconazole tablets should not be prescribed for any patient with underlying liver disease.  

https://www.medscape.com/answers/213853-26561/what-is-the-role-of-ketoconazole-in-the-treatment-of-candidiasis

Initial Tx for candidemia in non-neutropenic adult

1. echinocandin 

2. fluconazole, if not critically ill and not fluconazole-resistant (glabrata or krusei)

3. amphotericin B lipid formulation

UpToDate Treatment of candidemia and invasive candidiasis in adults

ketoconazole black box warning: Because ketoconazole tablets have been associated with serious adverse effects, ketoconazole tablets are not indicated for the treatment of onychomycosis, cutaneous dermatophyte infections, or Candida infections. Use ketoconazole only when other effective antifungal therapy is not available or tolerated and the potential benefits are considered to outweigh the potential risks.

UpToDate Ketoconazole (systemic): Drug information

恩恩 了解了! 

感謝4F. 6F. 7F的詳細解釋 :)

受益良多