What are the guideline sources, guidelines and references for Coccidioidomycosis ?
Guideline sources The following summarized guidelines for the evaluation and management of coccidioidomycosis are prepared by our editorial team based on guidelines from the Infectious Diseases Society of America (IDSA/CDC/NIH/HIVMA 2023), the Infectious Diseases Society of America (IDSA 2016), and the American Thoracic Society (ATS 2011). 1 3 4 Guidelines 1. Diagnostic procedures Cerebrospinal fluid analysis: As per IDSA 2016 guidelines, perform lumbar puncture with CSF analysis in patients with recently diagnosed coccidioidal infection only if having unusual, worsening or persistent headache, altered mental status, unexplained nausea or vomiting, or new focal neurologic deficit after adequate imaging of the CNS. B As per ATS 2011 guidelines, perform lumbar puncture with CSF analysis for presence of Coccidioides species in patients with primary coccidioidomycosis presenting with neurologic symptoms. B https://web.pathway.md/diseases/rectBqnHBRlSw42Wn 1/6 6/23/23, 3:25 AM Coccidioidomycosis Pathway 2. Medical management General principles: Ensure that patients with uncomplicated pulmonary coccidioidomycosis have a management plan incorporating regular medical follow-up, health education, and a plan for physical reconditioning. B Offer patient education, close observation, and supportive measures such as reconditioning physical therapy in patients with mild or non-debilitating symptoms, or substantially improved or resolved clinical illness by the time of diagnosis. B Indications for treatment: As per IDSA 2016 guidelines, initiate antifungal treatment in patients with significantly debilitating illness at the time of diagnosis. B Show 3 more As per ATS 2011 guidelines, do not offer antifungal treatment in most immunocompetent patients with primary pulmonary coccidioidomycosis without additional risk factors for dissemination. D Show 4 more Azoles: As per IDSA 2016 guidelines: Administer oral azoles in patients with ruptured coccidioidal cavities. B Administer oral azoles such as fluconazole at a daily dose of 400 mg, if treatment is initiated in non-pregnant adult patients. B As per ATS 2011 guidelines, consider administering triazole antifungal drugs for at least 3-6 months or longer if symptoms and radiographic abnormalities persist in immunocompetent patients with primary pulmonary coccidioidomycosis and moderate-to-severe symptoms, or if symptoms persist for > 6 weeks. C Show 2 more Amphotericin B: As per IDSA 2016 guidelines, administer IV amphotericin B in patients not tolerating oral azole therapy, or if 2 surgical procedures for control is required. B As per ATS 2011 guidelines: Reserve amphotericin B for the most severe cases of coccidioidomycosis or for patients not responding to azoles. B Prefer lipid formulations of amphotericin B, as those are better tolerated and allow treatment with a reduction in renal and other toxicities, recognizing that insufficient evidence that the newer lipid formulations of amphotericin B possess any greater efficacy than the conventional amphotericin B deoxycholate preparation. B 3. Surgical interventions https://web.pathway.md/diseases/rectBqnHBRlSw42Wn 2/6 6/23/23, 3:25 AM Coccidioidomycosis Pathway Indications for surgery: consider offering surgical options in patients with persistently symptomatic pulmonary cavities despite antifungal treatment. Consider performing surgery in patients with pulmonary cavities persisting for > 2 years and if symptoms recur whenever antifungal treatment is stopped. B Show 2 more 4. Specific circumstances Pregnant patients: consider initiating antifungal therapy in patients developing symptomatic coccidioidomycosis during pregnancy. B Show 14 more Infant patients: do not obtain coccidioidal serologic tests in infants during the first 3 months of life. Interpret positive tests with caution during the first year of life. D Show 2 more Patients with HIV, screening: As per IDSA/HIVMA/CDC/NIH 2023 guidelines, do not obtain routine testing in asymptomatic patients with human immunodeficiency virus not lived in or travelled to endemic regions. D As per IDSA 2016 guidelines: Obtain yearly serologic screening and CXR for coccidioidomycosis in coccidioidal-endemic regions. B Do not obtain serologic screening outside coccidioidal-endemic regions. D Patients with HIV, prevention: As per IDSA/HIVMA/CDC/NIH 2023 guidelines: Offer patients with human immunodeficiency virus avoiding extensive exposure to disturbed native soil, such as at building excavation sites, and advise staying inside during dust storms. B Do not administer primary antifungal prophylaxis (for individuals with negative results on serological tests for Coccidioides) in patients with human immunodeficiency virus with low CD4 counts living in coccidioidal-endemic regions. D As per IDSA 2016 guidelines, do not administer antifungal prophylaxis for the prevention of coccidioidomycosis in patients infected with human immunodeficiency virus living in coccidioidal-endemic regions. D Patients with HIV, antifungal therapy: As per IDSA/HIVMA/CDC/NIH 2023 guidelines, initiate an oral triazole in patients with clinically mild coccidioidal infection, such as focal pneumonia. B Show 14 more As per IDSA 2016 guidelines, initiate antifungal therapy in all patients with human immunodeficiency virus with clinical evidence of coccidioidomycosis and a peripheral blood CD4+ T-lymphocyte count < 250 cells/ L. B https://web.pathway.md/diseases/rectBqnHBRlSw42Wn 3/6 6/23/23, 3:25 AM Coccidioidomycosis Pathway Show 2 more Patients with HIV, antiretroviral therapy: As per IDSA/HIVMA/CDC/NIH 2023 guidelines: Do not delay ART while treating coccidioidomycosis. D Consider delaying ART for 4-6 weeks after initiating antifungal therapy in severely immunosuppressed (CD4 counts < 100 cells/mm ) patients with disseminated or CNS disease. C As per IDSA 2016 guidelines, do not delay potent ART because of the concern about coccidioidal immune reconstitution inflammatory syndrome. D Patients with HIV (pregnant patients): administer IV amphotericin B, formulated with deoxycholate or as a lipid preparation, as the preferred treatment in patients with non-meningeal coccidioidomycosis during the first trimester of pregnancy. B Show 3 more Patients with HIV (pediatric patients): manage pediatric patients with human immunodeficiency virus infection and coccidioidomycosis as adult patients. B Transplant recipients: administer fluconazole 400 mg daily or the equivalent dose based upon renal function for the treatment of clinically stable autologous or allogeneic hematopoietic stem cell transplant or solid organ transplant recipients with acute or chronic pulmonary coccidioidomycosis with normal renal function. B Show 5 more Recipients of biological response modifiers: administer oral azole therapy in recipients of biological response modifiers unless their coccidioidomycosis is severe enough to initiate IV amphotericin B. B Show 2 more Patients with diffuse pulmonary coccidioidomycosis: Administer liposomal amphotericin B (5 mg/kg/day) or amphotericin B (0.7-1.0 mg/kg/day) until clinical improvement, followed by fluconazole (400 mg/day) or itraconazole (400 mg/day) for at least another year in patients with diffuse pulmonary coccidioidomycosis with significant impairment of gas exchange. B Consider continuing azole therapy indefinitely in patients with ongoing immune suppression. Patients with chronic pulmonary coccidioidomycosis: As per IDSA 2016 guidelines, administer oral azoles such as fluconazole or itraconazole in patients with symptomatic chronic cavitary coccidioidal pneumonia. B As per ATS 2011 guidelines, initiate antifungal treatment in patients with chronic pulmonary coccidioidomycosis, defined as symptoms ongoing > 3 months, recognizing that it frequently occurs in patients with underlying lung disease. B Show 2 more Patients with non-meningeal disseminated disease: https://web.pathway.md/diseases/rectBqnHBRlSw42Wn 4/6 6/23/23, 3:25 AM Coccidioidomycosis Pathway Administer fluconazole (400 mg/day) or itraconazole (400 mg/day) for at least a year and until clinical improvement and stabilization in patients with non-meningeal disseminated disease. B Consider administering liposomal amphotericin B (5 mg/kg/day) or amphotericin B (0.7-1.0 mg/kg/day) until clinical improvement, followed by fluconazole (400 mg/day) or itraconazole (400 mg/day) for at least another year in patients with severe or refractory disease. C Patients with coccidioidal meningitis: As per IDSA 2016 guidelines, administer fluconazole 400-1,200 mg PO daily as initial therapy in most patients with coccidioidal meningitis and normal renal function. B Do not administer fluconazole < 400 mg daily in adult patients without substantial renal impairment. Show 9 more As per ATS 2011 guidelines, counsel an expert for the management of patients with coccidioidal meningitis given the risk of hydrocephalus and other complications even in the face of appropriate antifungal therapy. Consider managing patients with disseminated coccidioidomycosis and meningitis in conjunction with clinicians with appropriate expertise in the treatment of coccidioidal meningitis. B Show 2 more Patients with bone and joint coccidioidomycosis: As per IDSA 2016 guidelines: Administer azoles in patients with bone and joint coccidioidomycosis, unless the patient has extensive or limb-threatening skeletal or vertebral disease causing imminent cord compromise. B Administer amphotericin B as initial therapy, with eventual change to azole therapy for the long term in patients with severe osseous disease. B As per ATS 2011 guidelines, administer fluconazole (400 mg/day) or itraconazole (400 mg/day) in patients with bone and joint coccidioidomycosis, recognizing that itraconazole has greater efficacy. B Patients with extrapulmonary soft tissue coccidioidomycosis: initiate antifungal therapy in all patients with extrapulmonary soft tissue coccidioidomycosis. B Show 2 more 5. Follow-up and surveillance Observation: consider observing patients with pulmonary coccidioidomycosis and pulmonary nodules only for at least 1 year without antifungal treatment. C Follow-up: follow-up all patients with primary pulmonary coccidioidomycosis for at least 1 year to assure complete resolution and absence of complications. B References https://web.pathway.md/diseases/rectBqnHBRlSw42Wn 5/6 6/23/23, 3:25 AM Coccidioidomycosis Pathway 1. Galgiani JN, Ampel NM, Blair JE et al. 2016 Infectious Diseases Society of America IDSA Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clin Infect Dis. 2016 Sep 15;63 6):e112 46. Open 2. Kaplan JE, Benson C, Holmes KK et al. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep. 2009 Apr 10;58 RR 4 1 207. Open 3. Panel on Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Department of Health and Human Services. 2023. Open 4. Andrew H Limper, Kenneth S Knox, George A Sarosi et al. An official American Thoracic Society statement: Treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit Care Med. 2011 Jan 1;183 1 96 128. Open 5. George R Thompson rd, Thuy Le, Ariya Chindamporn et al. Global guideline for the diagnosis and management of the endemic mycoses: an initiative of the European Confederation of Medical Mycology in cooperation with the International Society for Human and Animal Mycology. Lancet Infect Dis. 2021 Dec;21 12):e364-e374. Open https://web.pathway.md/diseases/rectBqnHBRlSw42Wn 6/6