Fungal Infections

Question 1

Soft tissue cocci management

Answer 1

We recommend antifungal therapy in all cases of extrapul- monary soft tissue coccidioidomycosis (strong, moderate). 14. We recommend oral azoles, in particular fluconazole or itraconazole, for first-line therapy of extrapulmonary soft tis- sue coccidioidomycosis (strong, moderate).

Question 2

Bone/joint cocci management

Answer 2

We recommend azole therapy for bone and joint coccidi- oidomycosis, unless the patient has extensive or limb- threatening skeletal or vertebral disease causing imminent cord compromise (strong, low). 17. For severe osseous disease, we recommend AmB as initial therapy, with eventual change to azole therapy for the long term (strong, low).

Question 3

Cocci meningitis management

Answer 3

For CM, we recommend fluconazole 400–1200 mg orally daily as initial therapy for most patients with normal renal function (strong, moderate). There is no role for a dose <400 mg daily in the adult patient without substantial renal impairment. Some experts prefer to use itraconazole 200 mg 2–4 times daily, but this requires closer monitoring to assure adequate absorption, and there are more drug–drug interac- tions than with fluconazole.

Failure: higher doses are a first option (strong, moderate). Alternative options are to change therapy to another orally administered azole, or to initiate intrathecal AmB therapy.

Maintenance: For CM, we recommend azole treatment for life (strong, moderate)

Question 4

Management of disseminated & progressive cocci

Answer 4

For the treatment of patients with very severe and/or rapidly progressing acute pulmonary or disseminated coccidioidomycosis, we recommend the use of AmB until the patient has stabilized, followed by fluconazole

Question 5

Cocci recs for organ transplant patients in endemic region

Answer 5

For all patients undergoing organ transplantation in the endemic area without active coccidioidomycosis, we re- commend the use of an oral azole (eg, fluconazole 200 mg) for 6–12 months (strong, low).

Question 6

Cocci prevention in HIV

Answer 6

Antifungal prophylaxis is not recommended to prevent coccidioidomycosis in patients infected with HIV living in coccidioidal-endemic regions (strong, moderate).

Question 7

Cocci prevention in patients receiving biological

Answer 7

For patients in the endemic area, we recommend screening with Coccidioides serology prior to initiation of biologic re- sponse modifier therapy, as well as regular clinical follow- up for new signs and symptoms (strong, very low). We do not recommend regular serologic screening or antifungal prophylaxis in asymptomatic patients taking biologic re- sponse modifiers (BRMs) (strong, very low).