Blastomycosis medical therapy: Difference between revisions

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{{Blastomycosis}}
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{{CMG}}; {{AE}}; {{VB}}
{{CMG}}; {{AE}}{{VB}}{{ADG}}


==Overview==
==Overview==
As per the guidelines given by the Infectious Diseases Society of America the appropriate regimen must be guided by the clinical form and severity of disease, as well as the [[Immune system|immune status]] of patient and toxicity of [[Antifungal agent|antifungal agents]]. Only [[asymptomatic]] [[infections]] are left untreated, otherwise all cases need therapy.


==Medical Therapy==
*[[Immunocompetent]] patient. (Non-Life threatening infection): Drug of choice in this cases is usually [[Itraconazole]] or [[Amphotericin B|Lipid Amphotericin B]]. Alternatively, daily [[fluconazole]] or w may also be used.  
As per the guidelines given by the Infectious Diseases Society of America the appropriate regimen must be guided by the clinical form and severity of disease, as well as the immune status of patient and toxicity of antifungal agents. Only asymptomatic infections are left treated, otherwise all cases need therapy.  


* Immuno-competent patient.(Non-Life threatening infection)
*[[Immunocompetent]] patient. (Life threatening infection)
*# Drug of choice in this cases is usually Itraconazole or Lipid Amphotericin B. Alternatively, daily fluconazole or ketaconazole may also be used.  
**[[Pulmonary]] cases - These warrant treatment primarily with [[Amphotericin B|Lipid Amphotericin B]] or [[Amphotericin B|Deoxycholate Amphotericin B]]. Once the condition has been stabilized the patient may be switched to oral [[Itraconazole]] therapy.
**[[Disseminated disease|Disseminated]] cases - Drug of choice is same, however patients non tolerant to [[Amphotericin B]] can be treated with [[fluconazole]] or [[Itraconazole]].


* Immuno-competent patient.(Life threatening infection)
* [[Immunocompromised]] patients: All patients warrant treatment with [[Amphotericin B|Lipid Amphotericin B]] as the drug of choice and [[Itraconazole]] once the disease has shown clinical improvement.
*# Pulmonary cases - These warrant treatment primarily with Lipid Amphotericin B or Deoxycholate Amphotericin B. Once the condition has been stabilized the patient may be switched to oral Itraconazole therapy.
*# Disseminated cases - Drug of choice is same, however patients non tolerant to Amphotericin B can be treated with fluconazole or Itraconazole.


* Immuno-compromised patients.
==Medical Therapy==
*# All patients warrant treatment with Lipid Amphotericin B as the drug of choice and Itraconazole once the disease has shown clinical improvement.


===Antimicrobial Regimen===
===Antimicrobial Regimen===
*Blastomycosis
*'''Blastomycosis'''


:*'''Mild to moderate pulmonary blastomycosis'''
:*'''Mild to moderate pulmonary blastomycosis'''<ref name="pmid18462107">{{cite journal| author=Chapman SW, Dismukes WE, Proia LA, Bradsher RW, Pappas PG, Threlkeld MG et al.| title=Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2008 | volume= 46 | issue= 12 | pages= 1801-12 | pmid=18462107 | doi=10.1086/588300 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18462107  }} </ref>
::*Preferred regimen: [[Itraconazole]] 200 mg PO once or twice per day for 6–12 months  
::*Preferred regimen: [[Itraconazole]] 200 mg PO q12-24h for 6–12 months  
::*Note: Oral [[Itraconazole]], 200 mg 3 times per day for 3 days and then once or twice per day for 6–12 months, is recommended  
::*Note:Initially oral [[Itraconazole]], 200 mg for 3 days and then q12-24h for 6–12 months, is recommended  


:*'''Moderately severe to severe pulmonary blastomycosis'''
:*'''Moderately severe to severe pulmonary blastomycosis'''<ref name="pmid18462107">{{cite journal| author=Chapman SW, Dismukes WE, Proia LA, Bradsher RW, Pappas PG, Threlkeld MG et al.| title=Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2008 | volume= 46 | issue= 12 | pages= 1801-12 | pmid=18462107 | doi=10.1086/588300 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18462107  }} </ref>
::*Preferred regimen(1): Lipid amphotericin B (Lipid AmB) 3–5 mg/kg per day for 1–2 weeks {{and}} [[Itraconazole]] 200 mg PO bid for 6–12 months  
::*Preferred regimen(1): [[Amphotericin B|Lipid amphotericin B]] (Lipid AmB) 3–5 mg/kg IV  q 24h for 1–2 weeks {{and}} [[Itraconazole]] 200 mg PO q 12h for 6–12 months  
::*Preferred regimen(2): [[Amphotericin B]] deoxycholate 0.7–1 mg/kg per day for 1–2 weeks {{and}} [[Itraconazole]] 200 mg PO bid for 6–12 months
::*Preferred regimen(2): [[Amphotericin B]] deoxycholate 0.7–1 mg/kg IV  q 24h for 1–2 weeks {{and}} [[Itraconazole]] 200 mg PO q 12h for 6–12 months
::*Note: Oral [[Itraconazole]], 200 mg 3 times per day for 3 days and then 200 mg twice per day, for a total of 6–12 months, is recommended
::*Note: Oral [[Itraconazole]], 200 mg q8h for 3 days and then 200 mg q12h for 6–12 months, is recommended
    
    
:*'''Mild to moderate disseminated blastomycosis'''
:*'''Mild to moderate disseminated blastomycosis'''<ref name="pmid18462107">{{cite journal| author=Chapman SW, Dismukes WE, Proia LA, Bradsher RW, Pappas PG, Threlkeld MG et al.| title=Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2008 | volume= 46 | issue= 12 | pages= 1801-12 | pmid=18462107 | doi=10.1086/588300 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18462107  }} </ref>
::*Preferred regimen: [[Itraconazole]] 200 mg PO once or twice per day for 6–12 months  
::*Preferred regimen: [[Itraconazole]] 200 mg PO q12-24h  for 6–12 months  
::*Note(1): Treat osteoarticular disease for 12 months
::*Note(1): Treat [[Osteoarticular pain|osteoarticular]] disease for 12 months
::*Note(2): Oral [[Itraconazole]], 200 mg 3 times per day for 3 days and then 200 mg twice per day, for a total of 6–12 months, is recommended
::*Note(2): Oral [[Itraconazole]], 200 mg q8h for 3 days and then 200 mg q12h for a total of 6–12 months, is recommended


:*'''Moderately severe to severe disseminated blastomycosis'''
:*'''Moderately severe to severe disseminated blastomycosis'''<ref name="pmid18462107">{{cite journal| author=Chapman SW, Dismukes WE, Proia LA, Bradsher RW, Pappas PG, Threlkeld MG et al.| title=Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2008 | volume= 46 | issue= 12 | pages= 1801-12 | pmid=18462107 | doi=10.1086/588300 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18462107  }} </ref>
::*Preferred regimen(1): Lipid amphotericin B(Lipid AmB) 3–5 mg/kg per day, for 1–2 weeks {{and}} [[Itraconazole]] 200 mg PO bid for 6–12 months  
::*Preferred regimen(1): [[Amphotericin B|Lipid amphotericin B]](Lipid AmB) 3–5 mg/kg IV q24h for 1–2 weeks {{and}} [[Itraconazole]] 200 mg PO q12h for 6–12 months  
::*Preferred regimen(2): [[Amphotericin B]] deoxycholate 0.7–1 mg/kg per day, for 1–2 weeks {{and}} [[Itraconazole]] 200 mg PO bid for 6–12 months
::*Preferred regimen(2): [[Amphotericin B]] deoxycholate 0.7–1 mg/kg IV q24h for 1–2 weeks {{and}} [[Itraconazole]] 200 mg PO q12h for 6–12 months
::*Note: oral [[Itraconazole]], 200 mg 3 times per day for 3 days and then 200 mg twice per day, for a total of 6–12 months, is recommended
::*Note: oral [[Itraconazole]], 200 mg q8h for 3 days and then 200 mg q12h, for a total of 6–12 months, is recommended


:*'''CNS disease'''  
:*'''CNS disease'''<ref name="pmid18462107">{{cite journal| author=Chapman SW, Dismukes WE, Proia LA, Bradsher RW, Pappas PG, Threlkeld MG et al.| title=Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2008 | volume= 46 | issue= 12 | pages= 1801-12 | pmid=18462107 | doi=10.1086/588300 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18462107  }} </ref>
::*Preferred regimen: Lipid amphotericin B (Lipid AmB) 5 mg/kg per day for 4–6 weeks {{and}} an oral azole for at least 1 year  
::*Preferred regimen: [[Amphotericin B|Lipid amphotericin B]] (Lipid AmB) IV 5 mg/kg q24h for 4–6 weeks {{and}} an oral [[azole]] for at least 1 year  
::*Note(1): Step-down therapy can be with [[Fluconazole]], 800 mg per day {{or}} [[Itraconazole]], 200 mg 2–3 times per day {{or}} voriconazole, 200–400 mg twice per day.
::*Note(1): Step-down therapy can be with [[Fluconazole]], 800 mg per day {{or}} [[Itraconazole]], 200 mg q8-12h per day {{or}} [[voriconazole]], 200–400 mg q12h
::*Note(2): Longer treatment may be required for immunosuppressed patients.  
::*Note(2): Longer treatment may be required for [[immunosuppressed]] patients.  


:*'''Immunosuppressed patients'''  
:*'''Immunosuppressed patients'''<ref name="pmid18462107">{{cite journal| author=Chapman SW, Dismukes WE, Proia LA, Bradsher RW, Pappas PG, Threlkeld MG et al.| title=Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2008 | volume= 46 | issue= 12 | pages= 1801-12 | pmid=18462107 | doi=10.1086/588300 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18462107  }} </ref>
::*Preferred regimen(1): Lipid amphotericin B (Lipid AmB), 3–5 mg/kg per day, for 1–2 weeks, {{and}} [[Itraconazole]], 200 mg PO bid for 12 months  
::*Preferred regimen(1): [[Amphotericin B|Lipid amphotericin B]] (Lipid AmB), 3–5 mg/kg IV q24h  for 1–2 weeks, {{and}} [[Itraconazole]], 200 mg PO q12h for 12 months  
::*Preferred regimen(2): [[Amphotericin B]] deoxycholate, 0.7–1 mg/kg per day, for 1–2 weeks, {{and}} [[Itraconazole]], 200 mg PO bid for 12 months
::*Preferred regimen(2): [[Amphotericin B]] deoxycholate, 0.7–1 mg/kg IV q24h, for 1–2 weeks, {{and}} [[Itraconazole]], 200 mg POq12h for 12 months
::*Note(1): Oral [[Itraconazole]], 200 mg 3 times per day for 3 days and then 200 mg twice per day, for a total of 12 months, is recommended
::*Note(1): Oral [[Itraconazole]], 200 mg q8h for 3 days and then 200 mg q12h, for a total of 12 months, is recommended
::*Note(2): Life-long suppressive treatment may be required if immunosuppression cannot be reversed.  
::*Note(2): Life-long suppressive treatment may be required if [[immunosuppression]] cannot be reversed.  


:*'''Pregnant women'''
:*'''Pregnant women'''<ref name="pmid18462107">{{cite journal| author=Chapman SW, Dismukes WE, Proia LA, Bradsher RW, Pappas PG, Threlkeld MG et al.| title=Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2008 | volume= 46 | issue= 12 | pages= 1801-12 | pmid=18462107 | doi=10.1086/588300 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18462107  }} </ref>
::*Preferred regimen: Lipid amphotericin B (Lipid AmB) 3–5 mg/kg per day
::*Preferred regimen: [[Amphotericin B|Lipid amphotericin B]] (Lipid AmB) 3–5 mg/kg IV q24h
::*Note(1): Azoles should be avoided because of possible teratogenicity  
::*Note(1): [[Azoles]] should be avoided because of possible [[teratogenicity]]
::*Note(2): If the newborn shows evidence of infection, treatment is recommended with Amphotericin B deoxycholate, 1.0 mg/kg per day
::*Note(2): If the newborn shows evidence of [[infection]], treatment is recommended with [[Amphotericin B|Amphotericin B deoxycholate]], 1.0 mg/kg IV q24h


:*'''Children with mild to moderate disease'''  
:*'''Children with mild to moderate disease'''<ref name="pmid18462107">{{cite journal| author=Chapman SW, Dismukes WE, Proia LA, Bradsher RW, Pappas PG, Threlkeld MG et al.| title=Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2008 | volume= 46 | issue= 12 | pages= 1801-12 | pmid=18462107 | doi=10.1086/588300 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18462107  }} </ref>
::*Preferred regimen: [[Itraconazole]] 10 mg/kg PO per day for 6–12 months  
::*Preferred regimen: [[Itraconazole]] 10 mg/kg PO q24h for 6–12 months  
::*Note: Maximum dose 400 mg per day
::*Note: Maximum dose 400 mg q24h


:*'''Children with moderately severe to severe disease'''
:*'''Children with moderately severe to severe disease'''<ref name="pmid18462107">{{cite journal| author=Chapman SW, Dismukes WE, Proia LA, Bradsher RW, Pappas PG, Threlkeld MG et al.| title=Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2008 | volume= 46 | issue= 12 | pages= 1801-12 | pmid=18462107 | doi=10.1086/588300 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18462107  }} </ref>
::*Preferred regimen(1): Amphotericin B deoxycholate 0.7–1 mg/kg per day for 1–2 weeks {{and}} [[Itraconazole]] 10 mg/kg PO per day to a maximum of 400 mg per day for 6–12 months  
::*Preferred regimen(1): [[Amphotericin B|Amphotericin B deoxycholate]] 0.7–1 mg/kg IV q24h for 1–2 weeks {{and}} [[Itraconazole]] 10 mg/kg PO q24h to a maximum of 400 mg q24h for 6–12 months  
::*Preferred regimen(2): Lipid amphotericin B (Lipid AmB) 3–5 mg/kg per day for 1–2 weeks {{and}} [[Itraconazole]] 10 mg/kg PO per day to a maximum of 400 mg per day for 6–12 months  
::*Preferred regimen(2): [[Amphotericin B|Lipid amphotericin B]] (Lipid AmB) 3–5 mg/kg IV q24h for 1–2 weeks {{and}} [[Itraconazole]] 10 mg/kg PO q24h to a maximum of 400 mg q24h for 6–12 months  
::*Note: Children tolerate Amphotericin B deoxycholate better than adults do.
::*Note: Children tolerate [[Amphotericin B|Amphotericin B deoxycholate]] better than adults do.


==References==
==References==
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{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 20:37, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vidit Bhargava, M.B.B.S [2]Aditya Ganti M.B.B.S. [3]

Overview

As per the guidelines given by the Infectious Diseases Society of America the appropriate regimen must be guided by the clinical form and severity of disease, as well as the immune status of patient and toxicity of antifungal agents. Only asymptomatic infections are left untreated, otherwise all cases need therapy.

Medical Therapy

Antimicrobial Regimen

  • Blastomycosis
  • Mild to moderate pulmonary blastomycosis[1]
  • Preferred regimen: Itraconazole 200 mg PO q12-24h for 6–12 months
  • Note:Initially oral Itraconazole, 200 mg for 3 days and then q12-24h for 6–12 months, is recommended
  • Moderately severe to severe pulmonary blastomycosis[1]
  • Preferred regimen(1): Lipid amphotericin B (Lipid AmB) 3–5 mg/kg IV q 24h for 1–2 weeks AND Itraconazole 200 mg PO q 12h for 6–12 months
  • Preferred regimen(2): Amphotericin B deoxycholate 0.7–1 mg/kg IV q 24h for 1–2 weeks AND Itraconazole 200 mg PO q 12h for 6–12 months
  • Note: Oral Itraconazole, 200 mg q8h for 3 days and then 200 mg q12h for 6–12 months, is recommended
  • Mild to moderate disseminated blastomycosis[1]
  • Preferred regimen: Itraconazole 200 mg PO q12-24h for 6–12 months
  • Note(1): Treat osteoarticular disease for 12 months
  • Note(2): Oral Itraconazole, 200 mg q8h for 3 days and then 200 mg q12h for a total of 6–12 months, is recommended
  • Moderately severe to severe disseminated blastomycosis[1]
  • Preferred regimen(1): Lipid amphotericin B(Lipid AmB) 3–5 mg/kg IV q24h for 1–2 weeks AND Itraconazole 200 mg PO q12h for 6–12 months
  • Preferred regimen(2): Amphotericin B deoxycholate 0.7–1 mg/kg IV q24h for 1–2 weeks AND Itraconazole 200 mg PO q12h for 6–12 months
  • Note: oral Itraconazole, 200 mg q8h for 3 days and then 200 mg q12h, for a total of 6–12 months, is recommended
  • Immunosuppressed patients[1]
  • Preferred regimen(1): Lipid amphotericin B (Lipid AmB), 3–5 mg/kg IV q24h for 1–2 weeks, AND Itraconazole, 200 mg PO q12h for 12 months
  • Preferred regimen(2): Amphotericin B deoxycholate, 0.7–1 mg/kg IV q24h, for 1–2 weeks, AND Itraconazole, 200 mg POq12h for 12 months
  • Note(1): Oral Itraconazole, 200 mg q8h for 3 days and then 200 mg q12h, for a total of 12 months, is recommended
  • Note(2): Life-long suppressive treatment may be required if immunosuppression cannot be reversed.
  • Pregnant women[1]
  • Children with mild to moderate disease[1]
  • Preferred regimen: Itraconazole 10 mg/kg PO q24h for 6–12 months
  • Note: Maximum dose 400 mg q24h
  • Children with moderately severe to severe disease[1]

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Chapman SW, Dismukes WE, Proia LA, Bradsher RW, Pappas PG, Threlkeld MG; et al. (2008). "Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America". Clin Infect Dis. 46 (12): 1801–12. doi:10.1086/588300. PMID 18462107.

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