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• Coccidioidomycosis Return to Top

• 1.Primary pulmonary infection in patients low risk persistence/complication: Antifungal treatment not generally recommended. Treat fever weight loss and/or fatigue.

• 1.1 Primary pulmonary infection in patients with increased risk of complications or dissemination:

• Mild to moderate severity.Preferred regimen: Itraconazole solution 200 mg po or IV bid Template:OR Fluconazole 400 mg po q24h for 3–12 mo
• Locally severe or disseminated disease: Amphotericine B 0.6–1 mg/kg per day x 7 days then 0.8 mg/kg every other day or liposomal ampho B 3-5 mg/kg/d IV or ABLC 5 mg/kg/d IV, until clinical improvement (usually several wks or longer in disseminated disease), followed by itra or flu for at least 1 year.
• Note (1): Some use combination of Ampho B & Flu for progressive severe disease; controlled series lacking.
• Note (2): Consultation with specialist recommendation, surgery may be required.

• Meningitis:

• Adult:
• Preferred regimen: Fluconazole 400–1,000 mg po q24h indefinitely
• Alternative regimen: Ampho B IV as for pulmonary (above) + 0.1–0.3 mg daily intrathecal (intraventricular) via reservoir device. OR itra 400–800 mg q24h OR voriconazole
• Note (1): Some use combination of Ampho B & Flu for progressive severe disease; controlled series lacking.

• Child:
• Preferred regimen: Fluconazole (po) (Pediatric dose not established, 6 mg per kg q24h used)
• Alternative regimen: Ampho B IV as for pulmonary (above) + 0.1–0.3 mg daily intrathecal (intraventricular) via reservoir device. OR itra 400–800 mg q24h OR voriconazole

• Meningitis AIDS patients

Preferrered regimen: Induction phase, Amphotericin B 0.7 mg/kg IV + flucytosine 25 mg/kg PO four times a day × 2 wks, then fluconazole 400 mg PO once daily × 8 wks, then 200 mg PO once daily until CD4 >200 × >6 mos.

• Note (1): Monitor 5-FC levels and CBC to avoid bone marrow suppression.

• Alternative regimen: Above without flucytosine, but need to treat for 4-6 wks of ampho B or 12 wks of fluconazole 1200 mg/day (especially if neutropenic).
• Fluconazole alternative: itraconazole (not as effective). Ampho B alternative liposomal AmB 4-6 mg/kg/day IV.
• Maintenance phase: fluconazole 200 mg PO once daily life long or discontinue maintenance fluconazole when CD4 >200 × 6 mos and completed 10 wks rx minimum and asymptomatic. CSF pressure OP > 250 mm H2O: remove CSF fluid until pressure drops 50%, then daily LP with same rule until OP <200 mm H2O.