Blastomycosis medical therapy

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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.

• Immunocompetent patient.(Non-Life threatening infection): Drug of choice in this cases is usually Itraconazole or Lipid Amphotericin B. Alternatively, daily fluconazole or w may also be used.

• Immunocompetent patient.(Life threatening infection)
  • 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.

• Immunocompromised patients: All patients warrant treatment with Lipid Amphotericin B as the drug of choice and Itraconazole once the disease has shown clinical improvement.

Medical Therapy

Antimicrobial Regimen

• Blastomycosis

• Mild to moderate pulmonary blastomycosis

• Preferred regimen: Itraconazole 200 mg PO once or twice per day 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

• Moderately severe to severe pulmonary blastomycosis

• 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(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
• 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

• Mild to moderate disseminated blastomycosis

• Preferred regimen: Itraconazole 200 mg PO once or twice per day for 6–12 months
• Note(1): Treat 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

• Moderately severe to severe disseminated blastomycosis

• 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(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
• 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

• CNS disease

• 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
• 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(2): Longer treatment may be required for immunosuppressed patients.

• Immunosuppressed patients

• 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(2): Amphotericin B deoxycholate, 0.7–1 mg/kg per day, for 1–2 weeks, AND Itraconazole, 200 mg PO bid 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(2): Life-long suppressive treatment may be required if immunosuppression cannot be reversed.

• Pregnant women

• Preferred regimen: Lipid amphotericin B (Lipid AmB) 3–5 mg/kg per day
• 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

• Children with mild to moderate disease

• Preferred regimen: Itraconazole 10 mg/kg PO per day for 6–12 months
• Note: Maximum dose 400 mg per day

• Children with moderately severe to severe disease

• 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(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
• Note: Children tolerate Amphotericin B deoxycholate better than adults do.