Sporotrichosis medical therapy: Difference between revisions

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{{Sporotrichosis}}
{{Sporotrichosis}}


{{CMG}}
{{CMG}}; {{AE}} {{AJL}}
 
==Overview==
Because spontaneous resolution in cases of sporotrichosis is a rarity, the majority of patients require treatment. The recommended treatment regimens are largely empirical and predominantly based upon retrospective evaluations, case study reports, and nonrandomized control trials. The predominant therapy for sporotrichosis is [[itraconazole]], which is used as the primary treatment in [[immunocompetent]] patients, and as a suppressive therapy in [[Immunocompromised host|immunocompromised patients]]. The primary line of treatment for  [[Immunocompromised host|immunocompromised patients]] is [[amphotericin B]].


==Treatment==
==Treatment==
Treatment of sporotrichosis depends on the severity and location of the disease. The following are treatment options for this condition:<ref>{{cite journal |author=Lortholary O, Denning DW, Dupont B |title=Endemic mycoses: a treatment update |journal=J. Antimicrob. Chemother. |volume=43 |issue=3 |pages=321–31 |year=1999 |pmid=10223586 |url=http://jac.oxfordjournals.org/cgi/content/full/43/3/321 |doi=10.1093/jac/43.3.321}}</ref>
Because spontaneous resolution in cases of sporotrichosis is a rarity, the majority of patients require treatment. The recommended treatment regimens are largely empirical and predominantly based upon retrospective evaluations, case study reports, and nonrandomized control trials.<ref name="pmid17968818">{{cite journal| author=Kauffman CA, Bustamante B, Chapman SW, Pappas PG, Infectious Diseases Society of America| title=Clinical practice guidelines for the management of sporotrichosis: 2007 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2007 | volume= 45 | issue= 10 | pages= 1255-65 | pmid=17968818 | doi=10.1086/522765 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17968818  }} </ref>
The chart below outlines the effective treatment methods based upon the form of sporotrichosis displayed by an infected human host.
{| class="wikitable" style="border: 0px; font-size: 90%; margin: 3px; width: 80%" align="center" |


*Saturated [[potassium iodide]] solution
|+
:Although its mechanism is unknown, application of potassium iodide in droplet form can cure cutaneous sporotrichosis. This usually requires 3 to 6 months of treatment.
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Form}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Primary Line of Treatment}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Alternative Treatment}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Remarks/Other}}
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" | Uncomplicated cutaneous
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Itraconazole]] 200 mg PO qd
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Itraconazole]] 200 mg PO bid, {{Or}}
* [[Terbinafine]] 500 mg PO bid, {{Or}}
* [[Potassium iodide|SSKI]] increasing doses from 5 drops tid for one month to 40-50 drops qd, {{Or}}
* [[Fluconazole]] 400-800 mg PO qd, {{Or}}
* Local [[hyperthermia]]
| style="padding: 5px 5px; background: #F5F5F5;" |Continue treatment for 2-4 weeks after lesions resolve.
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Osteoarticular
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Itraconazole]] 200 mg PO bid
| style="padding: 5px 5px; background: #F5F5F5;" |
* Limposomal [[amphotericin B]] 3-5 mg/kg IV qd '''<u>OR</u>'''
* Deoxycholate [[amphotericin B]] 0.7-1 mg/kg IV qd until symptom resolution
| style="padding: 5px 5px; background: #F5F5F5;" |For a total of 12 months, switch to [[Itraconazole]] after resolution/end of treatment.
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Pulmonary
| style="padding: 5px 5px; background: #F5F5F5;" |
* Limposomal [[amphotericin B]] 3-5 mg/kg IV qd '''<u>THEN</u>'''
* [[Itraconazole]] 200 mg PO bid
| style="padding: 5px 5px; background: #F5F5F5;" |
* Deoxycholate [[amphotericin B]] 0.7-1 mg/kg IV qd '''<u>THEN</u>'''
* [[Itraconazole]] 200 mg PO bid upon symptom resolution
| style="padding: 5px 5px; background: #F5F5F5;" |Treat less sever cases with a 12 month regimen of [[Itraconazole]].
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Meningeal
| style="padding: 5px 5px; background: #F5F5F5;" |
* Limposomal amphotericin B 3-5 mg/kg IV qd '''<u>THEN</u>'''
* [[Itraconazole]] 200 mg PO bid
| style="padding: 5px 5px; background: #F5F5F5;" |
* Deoxycholate [[amphotericin B]] 0.7-1 mg/kg IV qd '''<u>THEN</u>'''
* [[Itraconazole]] 200 mg PO bid upon symptom resolution
| style="padding: 5px 5px; background: #F5F5F5;" |Precise length of [[amphotericin B]] treatment varies. Suppressive treatment with [[Itraconazole]] is necessary.  
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Dissimated
| style="padding: 5px 5px; background: #F5F5F5;" |
* Limposomal amphotericin B 3-5 mg/kg IV qd '''<u>THEN</u>'''
* [[Itraconazole]] 200 mg PO bid.
| style="padding: 5px 5px; background: #F5F5F5;" |
* Deoxycholate [[amphotericin B]] 0.7-1 mg/kg IV qd '''<u>THEN</u>'''
* [[Itraconazole]] 200 mg PO bid upon symptom resolution
| style="padding: 5px 5px; background: #F5F5F5;" |Continue [[amphotericin B]] treatment until patient shows marked improvement for a minimum of 12 months. Suppressive treatment with [[Itraconazole]] is necessary.
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Sporotrichosis in pregnant women
| colspan="2" style="padding: 5px 5px; background: #F5F5F5;" |
* Treat with limposomal [[amphotericin B]] 3-5 mg/kg IV qd '''<u>OR</u>'''
* Deoxycholate [[amphotericin B]] 0.7-1 mg/kg IV qd only for severe cases of sporotrichosis '''<u>OR</u>'''
* In cases of uncomplicated cutaneous, treat with only hyperthermia.


*[[Itraconazole]] (Sporanox) and [[fluconazole]]
| style="padding: 5px 5px; background: #F5F5F5;" |It is preferable to defer treatment in uncomplicated cases.  
:These are [[Antifungal medication|antifungal]] drugs.  Itraconazole is currently the drug of choice and is significantly more effective than fluconazole. Fluconazole should be reserved for patients who cannot tolerate itraconazole.
|-
*[[Amphotericin B]]
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Sporotrichosis in Children
:This antifungal medication is delivered intravenously.  Many patients, however, cannot tolerate Amphotericin B due to its potential side effects of fever, nausea, and vomiting.
| style="padding: 5px 5px; background: #F5F5F5;" |
Lipid formulations of amphotericin B are usually recommended instead of amphotericin B deoxycholate because of a better adverse-effect profile. Amphotericin B can be used for severe infection during pregnancy. For children with disseminated or severe disease, amphotericin B deoxycholate can be used initially, followed by itraconazole.<ref name="dbt.consultantlive.com">Hogan BK, Hospenthal DR. [http://dbt.consultantlive.com/display/article/1145628/1545568 Update on the therapy for sporotrichosis]. Drug Benefit Trends. 2010;22:49-52.</ref>
* [[Itraconazole]] 6-10 mg PO qd to a max of 400 mg PO qd for mild cases '''<u>OR</u>'''
 
* Deoxycholate [[amphotericin B]] 0.7-1 mg/kg IV qd for severe cases
:In case of sporotrichosis meningitis, the patient may be given a combination of Amphotericin B and 5-fluorocytosine/[[Flucytosine]].
| style="padding: 5px 5px; background: #F5F5F5;" |
 
* [[Potassium iodide|SSKI]] increasing doses equivalent to half the adult dose, continuing treatment for 2-4 weeks after resolution of symptoms.
*Newer [[triazole]]s
|
Several studies have shown that [[posaconazole]] has in vitro activity similar to that of amphotericin B and itraconazole; therefore, it shows promise as an alternative therapy. However, [[voriconazole]] susceptibility varies. Because the correlation between in vitro data and clinical response has not been demonstrated, there is insufficient evidence to recommend either posaconazole or voriconazole for treatment of sporotrichosis at this time.<ref name="dbt.consultantlive.com"/>
|}
 
<ref name="pmid17968818">{{cite journal| author=Kauffman CA, Bustamante B, Chapman SW, Pappas PG, Infectious Diseases Society of America| title=Clinical practice guidelines for the management of sporotrichosis: 2007 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2007 | volume= 45 | issue= 10 | pages= 1255-65 | pmid=17968818 | doi=10.1086/522765 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17968818  }} </ref> <ref name="pmid21976602">{{cite journal| author=Barros MB, de Almeida Paes R, Schubach AO| title=Sporothrix schenckii and Sporotrichosis. | journal=Clin Microbiol Rev | year= 2011 | volume= 24 | issue= 4 | pages= 633-54 | pmid=21976602 | doi=10.1128/CMR.00007-11 | pmc=PMC3194828 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21976602  }} </ref>
*[[Surgery]]
:In cases of bone infection and cavitatory nodules in the lungs, surgery may be necessary.
 
===Antimicrobial Regimen===
*'''Sporotrichosis'''<ref name="KauffmanBustamante2007">{{cite journal|last1=Kauffman|first1=C. A.|last2=Bustamante|first2=B.|last3=Chapman|first3=S. W.|last4=Pappas|first4=P. G.|title=Clinical Practice Guidelines for the Management of Sporotrichosis: 2007 Update by the Infectious Diseases Society of America|journal=Clinical Infectious Diseases|volume=45|issue=10|year=2007|pages=1255–1265|issn=1058-4838|doi=10.1086/522765}}</ref>:
:*1.'''Lymphocutaneous/cutaneous'''
::*Preferred regimen: [[Itraconazole]] 200mg PO qd
::*Alternative regimen (1): [[Itraconazole]] 200 mg PO bid 
 
::*Alternative regimen (2): [[Terbinafine]] 500 mg bid
 
::*Alternative regimen (3): Saturated solution potassium iodide(SSKI) with increasing doses
 
::*Alternative regimen (4): [[Fluconazole]] 400–800 mg qd 
 
::*Alternative regimen (5): local hyperthermia
::*Note(1): Treat for 2–4 weeks after lesions resolved
::*Note(2): SSKI initiated at a dosage of 5 drops (using a standard eyedropper) 3 times daily, increasing as tolerated to 40–50 drops 3 times daily
 
:*2.'''Osteoarticular'''
::*Preferred regimen: [[Itraconazole]] 200mg PO bid for 12 months
::*Alternative regimen (1): Lipid amphotericin B (Lipid AmB) 3–5 mg/kg/day
 
::*Alternative regimen (2): [[Amphotericin B]] deoxycholate 0.7–1 mg/kg/day
::*Note(1): Switch to [[Itraconazole]] after favorable response if AmB used
::*Note(2): Treat for a total of at least 12 months
 
:*3.'''Pulmonary'''
::*Preferred regimen(1): Lipid amphotericin B (Lipid AmB) 3–5 mg/kg/day for severe or life-threatening pulmonary sporotrichosis, then [[Itraconazole]] 200 mg PO bid
::*Preferred regimen(2): [[Itraconazole]] 200 mg PO bid for 12 months for less severe disease
::*Alternative regimen: [[Amphotericin B]] deoxycholate 0.7–1 mg/kg/d, then [[Itraconazole]] 200 mg PO bid {{or}} surgical removal
::*Note(1): Treat severe disease with an AmB formulation followed by [[Itraconazole]]
::*Note(2): Treat less severe disease with [[Itraconazole]]
::*Note(3): Treat for a total of at least 12 monthsSurgery combined with amphotericin B therapy is rec- ommended for localized pulmonary disease
 
:*4.'''Meningitis'''
::*Preferred regimen: Lipid amphotericin B (Lipid AmB) 5 mg/kg daily for 4–6 weeks, then [[Itraconazole]] 200 mg PO bid
::*Alternative regimen: [[Amphotericin B]] deoxycholate 0.7–1 mg/kg/d, then [[Itraconazole]] 200 mg PO bid
::*Note(1): Length of therapy with AmB not established, but therapy for at least 4–6 weeks is recommended.
::*Note(2): Treat for a total of at least 12 months.
::*Note(3): May require long-term suppression with [[Itraconazole]].
 
:*5.'''Disseminated'''
::*Preferred regimen: Lipid amphotericin B (Lipid AmB) 3–5 mg/kg/day, then [[Itraconazole]] 200 mg PO bid
::*Alternative regimen: [[Amphotericin B]] deoxycholate 0.7–1 mg/kg/day, then [[Itraconazole]] 200 mg PO bid
::*Note(1): Therapy with AmB should be continued until the patient shows objective evidence of improvement.
::*Note(2): Treat for a total of at least 12 months.
::*Note(3): May require long-term suppression with [[Itraconazole]].
 
:*6.'''Pregnant women'''
::*Preferred regimen(1): Lipid amphotericin B (Lipid AmB) 3–5 mg/kg/day {{or}} [[Amphotericin B]] deoxycholate 0.7–1 mg/kg/day  for severe sporotrichosis
::*Preferred regimen(2): Local hyperthermia for cutaneous disease.
::*Note(1): It is preferable to wait until after delivery to treat non–life-threatening forms of sporotrichosis.
::*Note(2): Azoles should be avoided.
 
:*7.'''Children'''
::*Preferred regimen:
:::*Mild disease: [[Itraconazole]] 6–10 mg/kg/day (400 mg/day maximum)
:::*Severe disease: [[Amphotericin B]] deoxycholate 0.7 mg/kg/day followed by [[Itraconazole]] 6–10 mg/kg up to a maximum of 400 mg PO daily, as step-down therapy
::*Alternative regimen: Saturated solution potassium iodide(SSKI) with increasing doses for mild disease initiated at a dosage of 1 drop (using a standard eyedropper) 3 times daily and increased as tolerated up to a maximum of 1 drop/kg or 40–50 drops 3 times daily, whichever is lowest


==References==
==References==
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[[Category:Disease]]
[[Category:Disease]]
[[Category:Infectious disease]]
 
[[Category:Infectious Disease Project]]
[[Category:Infectious Disease Project]]

Latest revision as of 19:06, 18 September 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alison Leibowitz [2]

Overview

Because spontaneous resolution in cases of sporotrichosis is a rarity, the majority of patients require treatment. The recommended treatment regimens are largely empirical and predominantly based upon retrospective evaluations, case study reports, and nonrandomized control trials. The predominant therapy for sporotrichosis is itraconazole, which is used as the primary treatment in immunocompetent patients, and as a suppressive therapy in immunocompromised patients. The primary line of treatment for immunocompromised patients is amphotericin B.

Treatment

Because spontaneous resolution in cases of sporotrichosis is a rarity, the majority of patients require treatment. The recommended treatment regimens are largely empirical and predominantly based upon retrospective evaluations, case study reports, and nonrandomized control trials.[1] The chart below outlines the effective treatment methods based upon the form of sporotrichosis displayed by an infected human host.

Form Primary Line of Treatment Alternative Treatment Remarks/Other
Uncomplicated cutaneous Continue treatment for 2-4 weeks after lesions resolve.
Osteoarticular For a total of 12 months, switch to Itraconazole after resolution/end of treatment.
Pulmonary Treat less sever cases with a 12 month regimen of Itraconazole.
Meningeal
  • Limposomal amphotericin B 3-5 mg/kg IV qd THEN
  • Itraconazole 200 mg PO bid
 Precise length of amphotericin B treatment varies. Suppressive treatment with Itraconazole is necessary.
Dissimated
  • Limposomal amphotericin B 3-5 mg/kg IV qd THEN
  • Itraconazole 200 mg PO bid.
 Continue amphotericin B treatment until patient shows marked improvement for a minimum of 12 months. Suppressive treatment with Itraconazole is necessary.
Sporotrichosis in pregnant women
  • Treat with limposomal amphotericin B 3-5 mg/kg IV qd OR
  • Deoxycholate amphotericin B 0.7-1 mg/kg IV qd only for severe cases of sporotrichosis OR
  • In cases of uncomplicated cutaneous, treat with only hyperthermia.
 It is preferable to defer treatment in uncomplicated cases.
Sporotrichosis in Children
  • Itraconazole 6-10 mg PO qd to a max of 400 mg PO qd for mild cases OR
  • Deoxycholate amphotericin B 0.7-1 mg/kg IV qd for severe cases
  • SSKI increasing doses equivalent to half the adult dose, continuing treatment for 2-4 weeks after resolution of symptoms.

[1] [2]

References

  1. ↑ 1.0 1.1 Kauffman CA, Bustamante B, Chapman SW, Pappas PG, Infectious Diseases Society of America (2007). "Clinical practice guidelines for the management of sporotrichosis: 2007 update by the Infectious Diseases Society of America". Clin Infect Dis. 45 (10): 1255–65. doi:10.1086/522765. PMID 17968818.
  2. ↑ Barros MB, de Almeida Paes R, Schubach AO (2011). "Sporothrix schenckii and Sporotrichosis". Clin Microbiol Rev. 24 (4): 633–54. doi:10.1128/CMR.00007-11. PMC 3194828. PMID 21976602.
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