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{{PBI|Coccidioidomycosis}} | {{PBI|Coccidioidomycosis}}<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. '''Primary pulmonary infection''' | :* 1. '''Primary pulmonary infection''' | ||
::* 1.1 '''Indications for antifungal therapy''' | ::* 1.1 '''Indications for antifungal therapy''' | ||
Line 32: | Line 32: | ||
::::* 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]] | ::::* 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''' | :* 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> | ||
::* 3.1 '''Clinically mild infections (e.g., focal pneumonia)''' | ::* 3.1 '''Clinically mild infections (e.g., focal pneumonia)''' | ||
:::* Preferred regimen: [[Fluconazole]] 400 mg PO daily {{or}} [[Itraconazole]] 200 mg PO bid | :::* Preferred regimen: [[Fluconazole]] 400 mg PO daily {{or}} [[Itraconazole]] 200 mg PO bid |
Revision as of 14:47, 23 July 2015
- Coccidioidomycosis[1]
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- 1. Primary pulmonary infection
- 1.1 Indications for antifungal therapy
- Immunosupression (AIDS, therapy with high dose corticosteroids, receiptients of TNF-alpha, receiptients of an organ transplant)
- Diabetes
- Preexisting cardiomyopathy
- Pregnancy (third trimester)
- Filipino or African
- Weight loss of > 10%
- Intense night sweats persisting longer than 3 weeks
- Infiltrates involving more than one-half of one lung or portions of both lungs
- Prominent or persistent hilar adenopathy
- 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[2]
- 3.1 Clinically mild infections (e.g., focal pneumonia)
- Preferred regimen: Fluconazole 400 mg PO daily OR Itraconazole 200 mg PO bid
- Alternative regimen (unresponsive to Fluconazole or Itraconazole): Posaconazole 200 mg PO bid OR Voriconazole 200 mg PO bid
- 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)
- 3.2.1 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.
- 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
- Note (1): Therapeutic drug monitoring and dosage adjustment may be necessary to ensure triazole antifungal and antiretroviral efficacy and reduce concentration-related toxicities.
- 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
- ↑ 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.
- ↑ "Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents" (PDF).