What are the guideline sources, guidelines and references for Histoplasmosis ?
Guideline sources The following summarized guidelines for the evaluation and management of histoplasmosis are prepared by our editorial team based on guidelines from the Infectious Diseases Society of America (IDSA/CDC/NIH/HIVMA 2023), the European Confederation of Medical Mycology (ECMM/ISHAM 2021), the Pan American Health Organization (PAHO/WHO 2020), the American Thoracic Society (ATS 2011), and the Infectious Diseases Society of America (IDSA 2007). 1 2 3 4 5 Guidelines 1. Classification and risk stratification Severity assessment: Define severe or moderately severe histoplasmosis as the presence of at least one sign or symptom involving vital organs: respiratory or circulatory failure neurological signs renal failure coagulation anomalies https://web.pathway.md/diseases/recuIBHLjJKnZaHrS 1/7 6/24/23, 12:45 PM Histoplasmosis Pathway general alteration of the WHO performance status > 2, in which the person is confined to a bed or chair for more than half the waking hours and only capable of limited self-care. Define mild-to-moderate histoplasmosis as signs and symptoms not including the above features defining severe or moderately severe histoplasmosis. 2. Diagnostic investigations Antigen testing: obtain circulating Histoplasma antigens for the diagnosis of disseminated histoplasmosis in patients with human immunodeficiency virus infection. B 3. Diagnostic procedures Histopathological analysis: obtain tissue for the histopathological diagnosis of histoplasmosis using fungal stains (Grocott methenamine silver staining) and fungal culture whenever possible. E 4. Medical management Management of acute pulmonary histoplasmosis, mild-to-moderate: As per ATS 2011 guidelines, do not initiate antifungal treatment in asymptomatic patients. D Show 2 more As per IDSA 2007 guidelines: Avoid initiating antifungal treatment in patients with mild-to-moderate pulmonary histoplasmosis. D Administer itraconazole 200 mg TID for 3 days and then 200 mg once daily or BID for 6-12 weeks in patients continuing to experience symptoms for > 1 month. B Management of acute pulmonary histoplasmosis, severe: As per ATS 2011 guidelines: Administer amphotericin B 0.7 mg/kg/day until clinical improvement is observed or until a cumulative dose of 2 g of amphotericin B is reached in patients with severe pulmonary histoplasmosis, such as patients with life-threatening pulmonary infections, including severe gas-exchange abnormality, severe toxicity, and rapid progression. B Consider initiating maintenance itraconazole 200 mg BID for at least 12 weeks in patients improving clinically after initial treatment with amphotericin B. B Consider administering adjunctive systemic corticosteroids (prednisone 40-60 mg/day or equivalent for 1-2 weeks) in patients with severe pulmonary histoplasmosis with diffuse pulmonary infiltrates or massive granulomatous mediastinitis. C As per IDSA 2007 guidelines: Administer lipid formulation of amphotericin B (3.0-5.0 mg/kg/day IV for 1-2 weeks, followed by itraconazole 200 mg TID for 3 days and then 200 mg BID, for a total of 12 weeks) in patients https://web.pathway.md/diseases/recuIBHLjJKnZaHrS 2/7 6/24/23, 12:45 PM Histoplasmosis Pathway with moderately severe to severe acute pulmonary histoplasmosis. Administer deoxycholate formulation of amphotericin B (0.7-1.0 mg/kg/day IV) as an alternative to a lipid formulation in patients at low risk for nephrotoxicity. B Administer methylprednisolone (0.5-1.0 mg/kg/day IV) during the first 1-2 weeks of antifungal therapy in patients developing respiratory complications, including hypoxemia or significant respiratory distress. B Management of progressive disseminated histoplasmosis: administer liposomal amphotericin B 3.0 mg/kg/day for 1-2 weeks, followed by oral itraconazole 200 mg TID for 3 days and then 200 mg BID, for a total of at least 12 months, in patients moderately severe to severe disease. A Show 6 more Management of chronic cavitary pulmonary histoplasmosis: Initiate itraconazole 200 mg TID for 3 days and then once daily or BID for at least 1 year in patients with chronic cavitary pulmonary histoplasmosis. B Measure blood levels of itraconazole after the patient has been receiving it for at least 2 weeks to ensure adequate drug exposure. B Management of pulmonary nodules: As per ATS 2011 guidelines, do not initiate antifungal treatment in asymptomatic patients with pulmonary nodules if Histoplasma cannot be cultured. D As per IDSA 2007 guidelines, do not initiate antifungal treatment in patients with pulmonary nodules (histoplasmomas). D Management of broncholithiasis: As per ATS 2011 guidelines, do not use antifungals in most patients with broncholithiasis. D Show 2 more As per IDSA 2007 guidelines: Do not initiate antifungal treatment in patients with broncholithiasis. D Perform bronchoscopic or surgical removal of the broncholith. B Management of pericarditis: administer NSAIDs in patients with mild pericarditis. B Show 3 more Management of mediastinal lymphadenitis: avoid initiating antifungal treatment in patients with mediastinal lymphadenitis. D Show 2 more Management of mediastinal granuloma: Avoid initiating antifungal treatment in patients with mediastinal granuloma. D Administer itraconazole 200 mg TID for 3 days and then once daily or BID for 6-12 weeks in symptomatic patients. B Management of fibrosing mediastinitis: As per ATS 2011 guidelines: Administer itraconazole 200 mg BID for 12 weeks in patients with fibrosing mediastinitis. Consider administering longer treatment, up to 12 months, in patients with radiographic or https://web.pathway.md/diseases/recuIBHLjJKnZaHrS 3/7 6/24/23, 12:45 PM Histoplasmosis Pathway physiologic improvement after an initial 12 weeks of therapy. B Do not use antifibrotic agents or systemic corticosteroids. B Consider performing placement of intravascular stents, C bronchoplasty, and/or placement of endobronchial stents, if appropriate expertise is available, in selected patients with fibrosing mediastinitis and severe vascular or airway compromise. Consider using removable stents initially if a decision is made to place a stent. C As per IDSA 2007 guidelines, do not initiate antifungal treatment in patients with mediastinal fibrosis. D Show 2 more Management of CNS histoplasmosis: Administer liposomal amphotericin B (5.0 mg/kg/day for a total of 175 mg/kg given over 4-6 weeks) followed by itraconazole (200 mg BID or TID) for at least 1 year and until resolution of CSF abnormalities, including Histoplasma antigen levels. B Monitor blood levels of itraconazole to ensure adequate drug exposure. B Management of rheumatologic syndromes: administer NSAIDs in patients with mild symptoms. B Show 2 more 5. Specific circumstances Pediatric patients: apply the same treatment indications and regimens in pediatric patients similar to adult patients, except that amphotericin B deoxycholate (1.0 mg/kg/day) is usually well tolerated and lipid preparations are not preferred. B Show 7 more Pregnant patients: Administer lipid formulation amphotericin B (3.0-5.0 mg/kg/day for 4-6 weeks) in pregnant patients. Administer deoxycholate formulation of amphotericin B (0.7-1.0 mg/kg daily) as an alternative to a lipid formulation in patients at low risk for nephrotoxicity. B Initiate treatment with amphotericin B deoxycholate (1.0 mg/kg/day for 4 weeks) if the newborn shows evidence of infection. B Patients with HIV, primary prophylaxis: As per IDSA/HIVMA/CDC/NIH 2023 guidelines, initiate primary prophylaxis in patients with a cluster of differentiation count < 150 cells/mm and at high risk because of occupational exposure or residence in a community with a hyperendemic rate of histoplasmosis (> 10 cases/100 patient-years). B Show 3 more As per IDSA 2007 guidelines: Initiate primary prophylaxis with itraconazole (200 mg daily) in patients with human immunodeficiency virus infection with a cluster of differentiation count < 150 cells/mm in https://web.pathway.md/diseases/recuIBHLjJKnZaHrS 4/7 6/24/23, 12:45 PM Histoplasmosis Pathway specific areas of endemicity where the incidence of histoplasmosis is > 10 cases per 100 patient-years. A Consider initiating primary prophylaxis with itraconazole (200 mg daily) in specific circumstances in other immunosuppressed patients. C Patients with HIV, management of mild-to-moderate pulmonary disease: As per IDSA/HIVMA/CDC/NIH 2023 guidelines: Administer itraconazole 200 mg PO TID for 3 days, then 200 mg PO BID for 12 months, B with dose adjustment based on interactions with antiretroviral therapy and itraconazole serum concentration, as the preferred induction and maintenance therapy in patients with less severe disseminated disease. B Administer any of the following as alternative therapy: posaconazole, ER tablet 300 mg PO BID for 1 day, then 300 mg PO once daily B voriconazole 400 mg PO BID for 1 day, then 200 mg PO BID B fluconazole 800 mg PO once daily. B As per ISHAM/ECMM 2021 guidelines, administer itraconazole for induction therapy in patients with less severe infection. E As per WHO/PAHO 2020 guidelines, administer itraconazole 200 mg TID for 3 days and then 200 mg BID in patients with human immunodeficiency virus and mild-to-moderate histoplasmosis. B As per ATS 2011 guidelines, administer itraconazole 200 mg TID for 3 days, followed by 200 mg BID for 12 months, in patients with mild-to-moderate histoplasmosis. B Patients with HIV, management of severe pulmonary disease: As per IDSA/HIVMA/CDC/NIH 2023 guidelines: Administer liposomal amphotericin B 3 mg/kg IV daily as the preferred induction therapy for 2 weeks or until clinically improved in patients with moderately severe to severe disseminated disease. A Administer amphotericin B lipid complex 5 mg/kg IV daily as an alternative therapy. B Initiate itraconazole 200 mg PO thrice times daily for 3 days, then BID for 12 months, B with dosage adjustment based on interactions with antiretroviral therapy and itraconazole serum concentration, as maintenance therapy. B As per ISHAM/ECMM 2021 guidelines, administer liposomal amphotericin B as first-line induction therapy in patients with advanced human immunodeficiency virus infection and moderate- to- severe histoplasmosis. Administer other amphotericin B formulations if liposomal amphotericin B is not available. E As per WHO/PAHO 2020 guidelines, initiate antiretroviral therapy as soon as possible in patients with disseminated histoplasmosis if CNS involvement is not suspected or proven. B Show 4 more As per ATS 2011 guidelines, administer amphotericin B 0.7-1.0 mg/kg/day (or a lipid formulation of amphotericin 3-5 mg/kg/day) until clinical improvement is observed or a cumulative dose of 2 g of amphotericin B is reached in patients with severe progressive disseminated histoplasmosis https://web.pathway.md/diseases/recuIBHLjJKnZaHrS 5/7 6/24/23, 12:45 PM Histoplasmosis Pathway requiring hospitalization. Consider administering itraconazole 200 mg BID for 12 months in patients improving clinically after initial treatment with amphotericin B. B Show 3 more Patients with HIV (management of chronic pulmonary disease): Initiate itraconazole 200 mg BID for 12-24 months in patients with chronic pulmonary histoplasmosis. B Initiate amphotericin B over itraconazole as initial therapy in patients with severe chronic pulmonary histoplasmosis. B Patients with HIV (management of meningeal disease): administer liposomal amphotericin B 5 mg/kg IV daily as induction therapy (4-6 weeks) for the management of meningeal disease in immunocompromised patients. B Show 2 more Patients with HIV (therapeutic drug monitoring): measure itraconazole serum concentrations in all patients after 2 weeks of therapy to ensure adequate absorption and to assess changes in hepatic metabolism due to drug interactions. B Patients with HIV (management of TB coinfection): treat tuberculosis according to the WHO guidelines in patients with human immunodeficiency virus with tuberculosis and histoplasmosis coinfection. B Patients with HIV (secondary prophylaxis): Initiate long-term suppressive therapy in patients with any of the following: severe disseminated or CNS infection after completing 12 months of treatment B relapse despite appropriate initial therapy. B Show 4 more 6. Preventative measures Antifungal prophylaxis: As per ATS 2023 guidelines, initiate primary prophylaxis in patients with a cluster of differentiation count < 150 cells/mm and at high risk because of occupational exposure or residence in a community with a hyperendemic rate of histoplasmosis (> 10 cases/100 patient- years). B Show 3 more As per IDSA 2007 guidelines: Initiate prophylaxis with itraconazole (200 mg/day) in patients with human immunodeficiency virus infection and a CD4 count < 150 cells/ L residing in areas with an incidence of histoplasmosis of > 10 cases per 100 patient-years. A Consider initiating prophylaxis with itraconazole (200 mg/day) in specific circumstances in other immunosuppressed patients. C https://web.pathway.md/diseases/recuIBHLjJKnZaHrS 6/7 6/24/23, 12:45 PM Histoplasmosis Pathway References 1. L Joseph Wheat, Alison G Freifeld, Martin B Kleiman et al. Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. Clin Infect Dis. 2007 Oct 1;45 7 807 25. Open 2. 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 3. 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 4. 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 5. No authors listed. Guidelines for Diagnosing and Managing Disseminated Histoplasmosis among People Living with HIV Internet]. Geneva: World Health Organization; 2020. Open 6. James H Diaz. Environmental and Wilderness-Related Risk Factors for Histoplasmosis: More Than Bats in Caves. Wilderness Environ Med. 2018 Dec;29 4 531 540. Open 7. Paige A Armstrong, Brendan R Jackson, Dirk Haselow et al. Multistate Epidemiology of Histoplasmosis, United States, 2011 2014. Emerg Infect Dis. 2018 Mar;24 3 425 431. Open https://web.pathway.md/diseases/recuIBHLjJKnZaHrS 7/7