What is the role of drug treatment for 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

In general, the severity and tempo of coccidioidomycosis dictates the approach to treatment. In patients with suspected or documented uncomplicated primary infection, treatment varies from careful observation to long-term azole therapy.

Some authors have suggested that empiric treatment may decrease the rate of disseminated infection, but this has not been proven in any controlled studies and no conclusive guidelines specify which uncomplicated infections need treatment. However, groups who are at risk for dissemination (eg, blacks, Filipinos, individuals with HIV or AIDS, individuals with diabetes mellitus, women in the third trimester of pregnancy) warrant more aggressive treatment.

Historically, amphotericin B has been the drug of choice to treat disseminated coccidioidomycosis. Oral azoles have provided a desirable alternative for both initial therapy and completion of courses after amphotericin therapy. The benefits of azoles include oral formulations and fewer adverse effects.

Azole antifungals are not used in pregnant women because these agents are teratogenic. Pregnant women may be treated with amphotericin B.

Patients with more advanced disease require more aggressive treatment. In particular, patients who exhibit signs of meningitis need either intravenous antibiotic therapy with amphotericin unless otherwise contraindicated or high-dose azole therapy with or without intrathecal amphotericin. Steroids may be somewhat beneficial in patients with vasculitis.

Effective antifungal therapy can be given in an outpatient or inpatient setting. The initial use of amphotericin may require an inpatient stay, and long-term amphotericin therapy requires placement of an indwelling intravenous catheter, such as a peripherally inserted central catheter (PICC) line.


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