Treatment of primary pulmonary coccidioidomycosis in nonpregnant patients

	Mild disease	Moderate disease (no respiratory compromise)*	Severe disease (respiratory compromise present)	Comment
Immunocompetent hosts				When initiating an azole, we typically prefer fluconazole. Although fluconazole and itraconazole appear to have similar efficacy for pulmonary infection, fluconazole has fewer side effects. When amphotericin is used for initial treatment, we prefer a lipid formulation (eg, liposomal amphotericin 3 to 5 mg/kg per day). All patients require monitoring, even if they do not require treatment. For those who were treated, monitoring should continue, even after therapy has been stopped, to assess for relapse.^◊
No risk factors for complications	No treatment.	Initiate therapy with fluconazole (400 mg orally daily) or itraconazole (200 mg orally twice daily). Duration is typically 6 to 12 weeks.^Δ	Initiate therapy with amphotericin B and a triazole antifungal, such as fluconazole (400 to 800 mg orally daily) or itraconazole (200 mg orally twice daily). Transition to triazole monotherapy when clinically stable. Duration is typically 12 to 24 weeks.^Δ
Risk factors for complications: African or Filipino Those with diabetes Frail older adults	Decision to treat is made on a case-by-case basis.^¶ If treatment is initiated, administer fluconazole (400 mg orally daily) or itraconazole (200 mg orally twice daily). Duration is typically 6 to 12 weeks.^Δ
Immunocompromised hosts
Immunocompromised hosts that are at high risk for severe disease: Patients with HIV and CD4 count <250 cells/microL Patients undergoing solid organ or hematopoietic cell transplant Patients with solid organ cancers receiving lymphodepleting chemotherapy Patients with hematologic malignancy Patients receiving immunosuppressive agents associated with reduced cellular immunity (eg, high-dose glucocorticoids, TNF-alpha inhibitor) CAR-T cell recipients Patients with specific gene mutations (eg, IFN-gammaR1, IL-12 receptor, STAT1, STAT3)	Initiate therapy with fluconazole (400 mg orally daily) or itraconazole (200 mg orally twice daily). Duration depends upon underlying condition. In addition, some patients may require suppressive therapy.^§	Initiate therapy with fluconazole (400 mg orally daily) or itraconazole (200 mg orally twice daily). Duration depends upon underlying condition. In addition, some patients may require suppressive therapy.^§	Initiate therapy with amphotericin B and a triazole antifungal, such as fluconazole (400 to 800 mg IV or orally daily) or itraconazole (200 mg orally twice daily). Transition to triazole monotherapy when clinically stable. Duration depends upon underlying condition. In addition, some patients may require suppressive therapy.^§

TNF: tumor necrosis factor; CAR: chimeric antigen receptor; IFN: interferon; IV: intravenous.

* Commonly used indicators for moderate disease include: infiltrates involving more than half of one lung or portions of both lungs, regardless of symptoms; persistent symptoms, including night sweats, for longer than three weeks; greater than 10% loss of body weight; anticoccidioidal complement-fixing antibody concentrations ≥1:32.

¶ These patients may be at risk for pulmonary or extrapulmonary complications. The decision to treat must balance the potential risks and benefits of treatment with azole therapy versus continued monitoring. Refer to the UpToDate topic on primary pulmonary coccidioidomycosis for a more detailed discussion.

Δ Duration depends in part upon the patient's response to therapy. Refer to the UpToDate topic that discusses primary pulmonary coccidioidomycosis for a discussion of duration of treatment.

◊ Refer to the UpToDate topics that discuss treatment of primary pulmonary coccidioidomycosis and coccidioidomycosis in immunocompromised hosts for discussions of monitoring.

§ Refer to the UpToDate topic that discusses coccidioidomycosis in immunocompromised hosts for a discussion of duration of treatments and the need for suppressive therapy in individual patient groups.

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Treatment of primary pulmonary coccidioidomycosis in nonpregnant patients