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{{PBI|Coccidioidomycosis}}
{{PBI|Histoplasmosis}}
:* 1. '''Primary pulmonary infection'''  <ref name="pmid16206093">{{cite journal| author=Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Johnson RH, Stevens DA et al.| title=Coccidioidomycosis. | journal=Clin Infect Dis | year= 2005 | volume= 41 | issue= 9 | pages= 1217-23 | pmid=16206093 | doi=10.1086/496991 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16206093  }} </ref>
:* 1. '''Acute pulmonary histoplasmosis:'''  <ref name="pmid16206093">{{cite journal| author=Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Johnson RH, Stevens DA et al.| title=Coccidioidomycosis. | journal=Clin Infect Dis | year= 2005 | volume= 41 | issue= 9 | pages= 1217-23 | pmid=16206093 | doi=10.1086/496991 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16206093  }} </ref>
::* 1.1 '''Indications for antifungal therapy'''
::* 1.1 '''Moderate severe or severe'''
::::* Immunosupression (AIDS, therapy with high dose corticosteroids, receiptients of TNF-alpha, receiptients of an organ transplant)
::::* Preferred regimen: Lipid formulation of amphotericin B (3.0–5.0 mg/kg daily intravenously for 1–2 weeks) followed by itraconazole (200 mg 3 times daily for 3 days and then 200 mg twice daily, for a total of 12 weeks) is recommended.
::::* Diabetes
::::* Preferred regimen (2): The deoxycholate formulation of amphotericin B (0.7–1.0 mg/kg daily intravenously) is an alternative to a lipid formulation in patients who are at a low risk for nephrotoxicity (A-III)
::::* Preexisting cardiomyopathy
::::* Preferred regimen (3): Methylprednisolone (0.5–1.0 mg/kg daily intravenously) during the first 1–2 weeks of antifungal therapy is recommended for patients who develop respiratory complications, including hypoxemia or significant respiratory distress (B-III).  
::::* Pregnancy (third trimester)
::::* Note (1): In severe cases, cases accompanied by respiratory insufficiency, or hypoxemia, anecdotal reports [49] suggest that corticosteroid therapy may hasten recovery
::::* Filipino or African
::::* Note (2): The pulmonary infiltrates should be resolved on the chest radiograph before antifungal therapy is stopped.
::::* Weight loss of > 10%
::* 1.2 '''Mild-to-Moderate:'''
::::* Intense night sweats persisting longer than 3 weeks
::::* Treatment is usually unnecessary
::::* Infiltrates involving more than one-half of one lung or portions of both lungs
::::* Patients who continue to have symptoms for >1 month: Itraconazole (200 mg 3 times daily for 3 days and then 200 mg once or twice daily for 6–12 weeks)
::::* Prominent or persistent hilar adenopathy
::::* Note (1): Antifungal treatment is unnecessary in patients with mild symptoms caused by acute pulmonary histoplasmosis
::::* Anticoccidiodial complement-fixing antibody concentrations in excess of 1:16
::* 1.2 '''Patients with low risk of complications or dissemination'''
::::* For many (if not most) patients, management may rely on periodic reassessment of symptoms and radiographic findings to assure resolution without antifungal treatment.
::* 1.3 '''Patients with high risk of complications or dissemination'''
:::* 1.3.1 '''Mild to moderate pneumonia'''
::::* Preferred regimen (1): [[Itraconazole]] solution 200 mg PO bid or IV q12h
::::* Preferred regimen (2): [[Fluconazole]] 400 mg PO q24h for 3–12 months
:::* 1.3.2 '''Locally severe or disseminated pneumonia'''
::::* Preferred regimen: ([[Amphotericin B]] 0.6–1 mg/kg PO qd every 7 days {{then}} 0.8 mg/kg PO every other day {{or}} [[Liposomal Amphotericin B]] 3-5 mg/kg IV q24 hrs {{or}} [[Amphotericin B lipid complex]] 5 mg/kg IV q24 hrs until clinical improvement) followed by [[Itraconazole]] {{or}} [[Fluconazole]] for at least 1 year.
::::* Note (1): Some use combination of Amphotericin B and Fluconazole for progressive severe disease; controlled series lacking.
::::* Note (2): Consultation with specialist recommendation, surgery may be required.


:* 2. '''Meningitis'''
::* 2.1 '''Adult'''
::::* Preferred regimen: [[Fluconazole]] 400–1,000 mg PO q24h indefinitely.
::::* Alternative regimen: [[Amphotericin B]] 3-5 mg/kg IV q24 hrs {{plus}} 0.1–0.3 mg qd intrathecal (intraventricular) via reservoir device {{or}} [[Itraconazole]] 400–800 mg q24h {{or}} [[Voriconazole]]
::::* Note: Some use combination of [[Amphotericin B]] and [[Fluconazole]] for progressive severe disease; controlled series lacking.
::* 2.2 '''Child'''
::::* Preferred regimen: [[Fluconazole]] PO (Pediatric dose not established, 6 mg per kg q24h used)
::::* Alternative regimen: [[Amphotericin B]] 3-5 mg/kg IV q24 hrs {{plus}} 0.1–0.3 mg daily intrathecal (intraventricular) via reservoir device {{or}} itra 400–800 mg q24h {{or}} [[Voriconazole]]


:* 3. '''Special considerations for HIV/AIDS patients'''<ref>{{ cite web | title = Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents | url = https://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultOITablesOnly.pdf }}</ref>
::* 2 '''Chronic Cavitary Pulmonary Histoplasmosis:'''
::* 3.1 '''Clinically mild infections (e.g., focal pneumonia)'''
::::* 2.1 Itraconazole (200 mg 3 times daily for 3 days and then once or twice daily for at least 1 year) is recommended
:::* Preferred regimen: [[Fluconazole]] 400 mg PO daily {{or}} [[Itraconazole]] 200 mg PO bid
::::* Note (1): Blood levels of itraconazole should be obtained after the patient has been receiving this agent for at least 2 weeks to ensure adequate drug exposure
:::* Alternative regimen (unresponsive to Fluconazole or Itraconazole): [[Posaconazole]] 200 mg PO bid {{or}} [[Voriconazole]] 200 mg PO bid
::::* Note (2): Patients with underlying emphysema often develop progressive pulmonary disease, which is characterized by cavities with surrounding inflammation, after infection with Hysotplasma capsulatum
:::* Note: Itraconazole, posaconazole, and voriconazole may have significant interactions with certain antiretro viral agents. These interactions are complex and can be bi-directional
 
::* 3.2 '''Severe, non-meningeal infection (diffuse pulmonary infection or severely ill patients with extrathoracic, disseminated disease)'''
::* 3 '''Pericarditis:'''
:::* 3.2.1 Preferred regimen: [[Amphotericin B]] deoxycholate 0.7–1.0 mg/kg IV q12hrs {{or}} Lipid formulation [[Amphotericin B]] 4–6 mg/kg IV q24hrs. Duration of therapy: continue until clinical improvement, then switch to an azole.
:::2.2 Mild cases
:::* 3.2.2 Alternative regimen: Some specialists will add a triazole ([[Fluconazole]] or [[Itraconazole]], with [[Itraconazole]] (preferred for bone disease) 400 mg per day to [[Amphotericin B]] therapy and continue triazole once [[Amphotericin B]] is stopped
::::* Nonsteroidal anti-inflammatory therapy is recommended
:::* Note (1): Therapeutic drug monitoring and dosage adjustment may be necessary to ensure triazole antifungal and antiretroviral efficacy and reduce concentration-related toxicities.
:::2.3 Patients with evidence of hemodynamic compromise or unremitting symptoms after several days of therapy with nonsteroidal anti-inflammatory therapy:
:::* Note (2): Therapy should be continued indefinitely in patients with diffuse pulmonary or disseminated diseases because relapse can occur in 25%–33% of HIV-negative patients. It can also occur in HIV-infected patients with CD4 counts >250 cells/μL
::* 3.3 '''Meningeal Infections'''
:::* Preferred regimen: [[Fluconazole]] 400–800 mg IV or PO daily
:::* Alternative regimen: [[Itraconazole]] 200 mg PO tid for 3 days {{then}} 200 mg PO bid {{or}} [[Posaconazole]] 200 mg PO bid {{or}} [[Voriconazole]] 200–400 mg PO bid {{or}} Intrathecal [[Amphotericin B]] deoxycholate when triazole antifungals are ineffective.
:::* Note (1): Intrathecal amphotericin B should only be given in consultation with a specialist and administered by an individual with experience with the technique.
:::* Note (2): Some patients with meningitis may develop hydrocephalus and require CSF shunting
:::* Note (3): Therapy should be lifelong in patients with meningeal infections because relapse occurs in 80% of HIV-infected patients after discontinuation of triazole therapy
::* 3.4 '''Chronic Suppressive Therapy'''
:::* Preferred regimen (1): [[Fluconazole]] 400 mg PO qd
:::* Preferred regimen (2): [[Itraconazole]] 200 mg PO bid
:::* Alternative regimen (1): [[Posaconazole]] 200 mg PO bid
:::* Alternative regimen (2): [[Voriconazole]] 200 mg PO bid


==References==
==References==
{{reflist}}
{{reflist}}

Revision as of 16:29, 24 July 2015

  • 1. Acute pulmonary histoplasmosis: [1]
  • 1.1 Moderate severe or severe
  • Preferred regimen: Lipid formulation of amphotericin B (3.0–5.0 mg/kg daily intravenously for 1–2 weeks) followed by itraconazole (200 mg 3 times daily for 3 days and then 200 mg twice daily, for a total of 12 weeks) is recommended.
  • Preferred regimen (2): The deoxycholate formulation of amphotericin B (0.7–1.0 mg/kg daily intravenously) is an alternative to a lipid formulation in patients who are at a low risk for nephrotoxicity (A-III)
  • Preferred regimen (3): Methylprednisolone (0.5–1.0 mg/kg daily intravenously) during the first 1–2 weeks of antifungal therapy is recommended for patients who develop respiratory complications, including hypoxemia or significant respiratory distress (B-III).
  • Note (1): In severe cases, cases accompanied by respiratory insufficiency, or hypoxemia, anecdotal reports [49] suggest that corticosteroid therapy may hasten recovery
  • Note (2): The pulmonary infiltrates should be resolved on the chest radiograph before antifungal therapy is stopped.
  • 1.2 Mild-to-Moderate:
  • Treatment is usually unnecessary
  • Patients who continue to have symptoms for >1 month: Itraconazole (200 mg 3 times daily for 3 days and then 200 mg once or twice daily for 6–12 weeks)
  • Note (1): Antifungal treatment is unnecessary in patients with mild symptoms caused by acute pulmonary histoplasmosis


  • 2 Chronic Cavitary Pulmonary Histoplasmosis:
  • 2.1 Itraconazole (200 mg 3 times daily for 3 days and then once or twice daily for at least 1 year) is recommended
  • Note (1): Blood levels of itraconazole should be obtained after the patient has been receiving this agent for at least 2 weeks to ensure adequate drug exposure
  • Note (2): Patients with underlying emphysema often develop progressive pulmonary disease, which is characterized by cavities with surrounding inflammation, after infection with Hysotplasma capsulatum
  • 3 Pericarditis:
2.2 Mild cases
  • Nonsteroidal anti-inflammatory therapy is recommended
2.3 Patients with evidence of hemodynamic compromise or unremitting symptoms after several days of therapy with nonsteroidal anti-inflammatory therapy:

References

  1. ↑ Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Johnson RH, Stevens DA; et al. (2005). "Coccidioidomycosis". Clin Infect Dis. 41 (9): 1217–23. doi:10.1086/496991. PMID 16206093.
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