What's the next step for a patient with a previously positive Histoplasma test now testing negative after one year?

From the Guidelines

For a patient with a previously positive Histoplasma test now testing negative after one year, the next step would be to discontinue antifungal therapy if the patient has completed an appropriate treatment course and shows clinical improvement, as indicated by the Infectious Diseases Society of America guidelines 1. The treatment course typically involves 6-12 months of itraconazole (200mg twice daily) for mild to moderate histoplasmosis, while severe cases may require initial amphotericin B followed by itraconazole 1. Some key points to consider in the management of histoplasmosis include:

• The use of liposomal amphotericin B (3.0 mg/kg daily) for 1–2 weeks, followed by oral itraconazole (200 mg 3 times daily for 3 days and then 200 mg twice daily for a total of at least 12 months) for moderately severe to severe disease 1
• The importance of monitoring antigen levels during therapy and for 12 months after therapy is ended to monitor for relapse 1
• The need for lifelong suppressive therapy with itraconazole (200 mg daily) in immunosuppressed patients if immunosuppression cannot be reversed 1 After stopping treatment, the patient should have follow-up appointments every 3-6 months for the first year to monitor for potential relapse, including clinical evaluation for recurrent symptoms and possibly repeat Histoplasma antigen testing if symptoms return 1. It is also important to note that immunocompromised patients require closer monitoring as they have higher relapse rates, and that a negative test after treatment indicates successful clearance of the infection, but the patient should be educated about potential symptoms of recurrence since Histoplasma can remain dormant in the body 1. If the patient develops new symptoms suggestive of histoplasmosis in the future, prompt medical evaluation would be necessary, and suppressive therapy may be resumed if patients become nonadherent with antiretroviral therapy, if antiretroviral therapy is failing, or if the CD4 T cell count decreases to <150 cells/mm3 1.

From the Research

Next Steps for a Patient with a Previously Positive Histoplasma Test Now Testing Negative

• The patient's condition and test results should be closely monitored to determine the best course of action 2.
• Since there is no direct evidence related to Histoplasma tests, the general principles of managing a patient with a previously positive test now testing negative should be considered.
• The patient's medical history, current condition, and any potential risks or complications should be taken into account when deciding on the next steps 3, 2.
• Regular follow-up appointments and further testing may be necessary to ensure the patient's condition is stable and to detect any potential changes or complications early on.

Considerations for Perioperative Antibiotic Prophylaxis (PAP)

• PAP is clearly indicated for operations that carry a high risk of surgical site infections (SSI) and for those that involve the implantation of alloplastic material 2.
• The basic principles of PAP, including administration by the anesthesia team and short-term use, should be followed to minimize the risk of toxicity, bacterial superinfections, and antibiotic resistance 2.
• The patient's individual risk factors for SSI, such as body-mass index and immunosuppression, should be assessed before any surgical procedure 2.

Quality Assurance and Monitoring

• A quality assurance system, such as the Pap Smear Quality Assurance (PAPQA) system, can be used to monitor the performance of physicians and ensure that patients receive appropriate care and follow-up 4.
• Regular monitoring and feedback can help improve the quality of care and detect any potential issues or complications early on 4.