2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis

Abstract

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.Coccidioidomycosis, also known as San Joaquin Valley fever, is a systemic infection endemic to parts of the southwestern United States and elsewhere in the Western Hemisphere. Residence in and recent travel to these areas are critical elements for the accurate recognition of patients who develop this infection. In this practice guideline, we have organized our recommendations to address actionable questions concerning the entire spectrum of clinical syndromes. These can range from initial pulmonary infection, which eventually resolves whether or not antifungal therapy is administered, to a variety of pulmonary and extrapulmonary complications. Additional recommendations address management of coccidioidomycosis occurring for special at-risk populations. Finally, preemptive management strategies are outlined in certain at-risk populations and after unintentional laboratory exposure.

Diagnosis and Management of Systemic Endemic Mycoses Causing Pulmonary Disease

“…Serology is the main method for diagnosing Coccidiodes infection in the USA, where EIAs for specific IgM and IgG are commercially available [39]. A confirmatory immunodiffusion test should be ordered after a positive EIA due to higher specificity [40].…”

“…A limitation is that antibodies will only form after a latency period of several weeks; therefore the absence of antibodies does not exclude infection in the early course of illness. Direct microscopic examination of clinical specimens and/or culture may be a faster means of diagnosing Coccidiodes infections [39]. Fungal growth can be observed within 1 week, and identification is followed by a commercially available Genprobe with detects C. immitis-specific nucleic acid sequence.…”

“…Fungal growth can be observed within 1 week, and identification is followed by a commercially available Genprobe with detects C. immitis-specific nucleic acid sequence. To assert disseminated coccidioidomycosis, it is usually necessary to visualize fungi in extrapulmonary biopsy specimens [39].…”

Large-Scale Evaluation of In Vitro Amphotericin B, Triazole, and Echinocandin Activity against Coccidioides Species from U.S. Institutions

“…Clinical manifestations vary depending on the extent of infection and the immune status of the host. Treatment of patients with coccidioidomycosis has largely consisted of therapy with amphotericin B formulations for those with severe disease or a triazole, most commonly fluconazole, for those with mild to moderate disease (1).…”

“…Fluconazole is the most frequently prescribed antifungal medication for the treatment of coccidioidomycosis and is considered first-line therapy for the majority of coccidioidal infections (1). Despite the lack of large-scale susceptibility studies, clinical experience suggests that higher fluconazole doses are often needed for a clinical response to be observed, and doses of 800 mg for primary infection are now routinely recommended by some experts (1).…”