From the Guidelines
The recommended treatment for histoplasmosis is itraconazole for mild to moderate cases, and liposomal amphotericin B for severe cases, followed by itraconazole for at least 12 months 1.
Treatment Overview
The treatment approach for histoplasmosis varies based on the severity and type of infection.
- For mild to moderate acute pulmonary histoplasmosis, treatment may not be necessary as it often resolves on its own.
- For more severe or disseminated infections, itraconazole is typically the first-line treatment, usually prescribed at 200 mg once or twice daily for 6-12 weeks.
- In severe cases requiring hospitalization, amphotericin B (lipid formulation at 3-5 mg/kg/day or deoxycholate at 0.7-1 mg/kg/day) is administered initially, followed by itraconazole once the patient improves.
Special Considerations
- For chronic pulmonary histoplasmosis, itraconazole is given for at least 12 months.
- Patients with compromised immune systems may require longer treatment durations, sometimes even lifelong suppressive therapy with itraconazole.
- These antifungal medications work by disrupting the fungal cell membrane, preventing the growth and reproduction of Histoplasma capsulatum.
- Treatment should be monitored with regular liver function tests as these medications can cause hepatotoxicity.
- Patients should also be aware that itraconazole has significant drug interactions and should be taken with food to enhance absorption.
Evidence Support
The recommendations are based on the clinical practice guidelines for the management of patients with histoplasmosis, which suggest that liposomal amphotericin B is recommended for 1–2 weeks, followed by oral itraconazole for at least 12 months 1. In patients with AIDS, the response rate was higher (88% vs. 64%) and the mortality rate was lower (2% vs. 13%) among recipients of liposomal amphotericin B 1.
From the FDA Drug Label
Amphotericin B for Injection USP is specifically intended to treat potentially life-threatening fungal infections: ... histoplasmosis... The recommended treatment for histoplasmosis is amphotericin B (IV), as it is specifically intended to treat this potentially life-threatening fungal infection 2.
- Key points:
- Amphotericin B for Injection USP is used to treat progressive, potentially life-threatening fungal infections
- Histoplasmosis is one of the fungal infections that amphotericin B is intended to treat
From the Research
Treatment Overview
The recommended treatment for histoplasmosis depends on the severity of the disease and the patient's immune status.
- For moderate to severe and disseminated presentations, amphotericin B is the drug of choice 3.
- Itraconazole is appropriate for mild disease and as step-down therapy after initial treatment with amphotericin B 4, 3, 5.
Treatment Options
- Itraconazole has been shown to be safe and effective induction therapy for mild disseminated histoplasmosis in patients with AIDS, offering an alternative to amphotericin B in such cases 4.
- Fluconazole can be used for chronic suppressive therapy of histoplasmosis in patients who cannot take itraconazole due to drug interactions, malabsorption, or side effects 6.
- Posaconazole may be a useful salvage treatment option for histoplasmosis involving a variety of infected tissues and organs 7.
Patient Considerations
- Patients with moderately severe or severe histoplasmosis should first be treated with amphotericin B and then may be switched to itraconazole after achieving clinical improvement 4.
- Immunocompromised patients and those with progressive disseminated disease or chronic pulmonary disease require treatment 5.