From the Guidelines
Treatment of coccidioidomycosis should be guided by disease severity and patient factors, with fluconazole being the first-line treatment for mild to moderate infections, typically prescribed at 400-800 mg daily for 3-6 months, as recommended by the 2016 Infectious Diseases Society of America (IDSA) clinical practice guideline 1.
Key Considerations
- For severe or disseminated disease, amphotericin B is recommended initially (0.5-1.0 mg/kg/day), followed by long-term azole therapy, as stated in the 2016 IDSA guideline 1.
- Itraconazole (200 mg twice daily) is an alternative option that may be more effective for skeletal infections, according to a randomized double-blind trial comparing fluconazole and itraconazole for nonmeningeal disseminated coccidioidomycosis 1.
- Treatment duration varies significantly, with uncomplicated pulmonary disease requiring 3-6 months, while disseminated or meningeal disease often requires lifelong therapy, as noted in the 2016 IDSA guideline 1.
- Immunocompromised patients generally need more aggressive and prolonged treatment, with fluconazole being the preferred agent for lifelong systemic suppressive treatment, as recommended by the 1997 USPHS/IDSA guidelines 1.
Special Considerations
- Regular monitoring of liver function is essential during antifungal therapy, as noted in the 2016 IDSA guideline 1.
- Surgical intervention may be necessary for complications like cavitary lesions or abscesses, as stated in the 2016 IDSA guideline 1.
- The treatment approach targets the fungus Coccidioides immitis/posadasii, which causes this infection primarily in the southwestern United States and parts of Latin America, with the goal of controlling fungal growth while the immune system develops an effective response, as noted in the 2016 IDSA guideline 1.
From the FDA Drug Label
Amphotericin B for Injection USP is specifically intended to treat potentially life-threatening fungal infections: ... coccidioido-mycosis...
- Treatment option: Amphotericin B (IV) can be used to treat coccidiodomycosis.
- Key consideration: This drug should be administered primarily to patients with progressive, potentially life-threatening fungal infections 2.
From the Research
Treatment Options for Coccidioidomycosis
- Antifungal therapy is not always required for primary pulmonary disease, but prolonged courses of antifungals are needed for extrathoracic disseminated disease 3
- Intravenous amphotericin B is reserved for severe disease, while oral triazole antifungals have had a significant impact on the management of coccidioidomycosis 3
- Fluconazole and itraconazole at 400 mg daily have been effective for various forms of coccidioidomycosis, including meningitis, but relapse after therapy is a problem 3, 4
Comparison of Antifungal Agents
- A randomized, double-blind trial compared oral fluconazole and itraconazole for progressive, nonmeningeal coccidioidomycosis, and found that itraconazole had a slightly greater efficacy at the doses studied 4
- Voriconazole and posaconazole have been used as salvage treatment for refractory coccidioidomycosis, with response rates of 67% and 75%, respectively 5
- Combination therapy with voriconazole and caspofungin has been used to treat pediatric refractory coccidioidomycosis, with 8 out of 9 patients achieving remission 6
Special Considerations
- Pregnant women, African-American men, and individuals with suppressed cellular immunity are at increased risk for symptomatic and severe coccidioidomycosis 3
- Treatment considerations for pulmonary coccidioidomycosis include the use of fluconazole, other azoles, and amphotericin B products, as well as the management of complicated infections and sequelae 7