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

1.1Uncomplicated acute coccidioidal pneumonia

  • 1.1.1 For many (if not most) patients, management may rely on periodic reassessment of symptoms and radiographic findings to assure resolution without antifungal treatment.
  • 1.1.2 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 110%
  • 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
  • 1.1.3 Antifungal regimenes
  • Preferred: Oral azole antifungal agents at dosages of 200–400 mg qd. Courses of typically recommended treatment range from 3 to 6 months.


  • 1.1 Primary pulmonary infection in patients with increased risk of complications or dissemination:
  • Preferred regimen in mild to moderate disease: Itraconazole solution 200 mg PO bid or IV q12h Template:OR Fluconazole 400 mg PO q24h for 3–12 months
  • Locally severe or disseminated disease: Amphotericin B 0.6–1 mg/kg per day by 7 days THEN 0.8 mg/kg every other day or liposomal amphothe 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: Amphotericin B IV as for pulmonary (above) + 0.1–0.3 mg daily intrathecal (intraventricular) via reservoir device Template:OR itra 400–800 mg q24h Template:OR Voriconazole
  • Note (1): Some use combination of Amphotericin B and Flu for progressive severe disease; controlled series lacking.
  • Child:


  • 2.Special considerations for HIV/AIDS patients
  • 2.1 Focal Pneumonia
  • 2.1.1 Mild Infections: Fluconazole 400 mg PO daily OR Itraconazole 200 mg PO BID
  • Alternative regimen for patients who failed to respond to fluconazole or itraconazole
Posaconazole 200 mg PO BID (BII), or

Voriconazole 200 mg PO BID (BIII)

  • 2.1.2 Severe Non-Meningeal Infection: Amphotericin B deoxycholate 0.7–1.0 mg/kg IV daily, Lipid formulation amphotericin B 4–6 mg/kg IV daily, Duration of therapy: continue until clinical improvement, then switch to an azole


  • 3. Meningingeal infections
  • Preferrered regimen: Fluconazole 400–800 mg IV or PO daily
  • Alternative regimen:

• Itraconazole 200 mg PO TID for 3 days, then 200 mg PO BID (BII), or

• Posaconazole 200 mg PO BID (BIII), or

• Voriconazole 200–400 mg PO BID (BIII), or

• Intrathecal amphotericin B deoxycholate, when triazole antifungals are ineffective (AIII):::* Chonic suppressive therapy: Fluconazole 400 mg PO daily (AII), or Itraconazole 200 mg PO BID


  • 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.




References