What is the role of azoles in the treatment of coccidioidomycosis?

Updated: Aug 27, 2019
  • Author: Duane R Hospenthal, MD, PhD, FACP, FIDSA, FASTMH; Chief Editor: Michael Stuart Bronze, MD  more...
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Answer

Itraconazole (400 mg/day) appears to have efficacy equal to that of fluconazole in the treatment of nonmeningeal infection and have the same relapse rate after therapy is discontinued. However, itraconazole seems to perform better in skeletal lesions, [67] whereas fluconazole performs better in pulmonary and soft tissue infection. Serum levels of itraconazole are commonly obtained at the onset of long-term therapy because its absorption is sometimes erratic and unpredictable.

Dosages vary but usually are as follows:

  • Amphotericin B deoxycholate - 0.5-1.5 mg/kg/day IV

  • Lipid formulations of amphotericin B - 2-5 mg/kg/day IV

  • Ketoconazole - 400 mg/day orally

  • Itraconazole - 200 mg 2-3 times/day orally

  • Fluconazole - 400-800 mg/day orally or IV

For patients who are unresponsive to fluconazole, options are limited. Several case reports have studied the efficacy of 3 newer antifungal agents in the treatment of disease that is refractory to first-line therapy: posaconazole and voriconazole (triazole compounds similar in structure to fluconazole) and caspofungin (glucan synthesis inhibitor of the echinocandin structural class). [68, 69, 70] However, these drugs have not been FDA approved, and clinical trials are lacking. Susceptibility testing of Coccidioides species in one report revealed uniform susceptibility to most antifungal agents, including these newer drugs. [71]


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