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"Clinical Practice Guidelines for the Management of Blastomycosis"

current
Published: Clinical Infectious Diseases ; 2008 ; 63 : 112 -146

Abstract

Blastomycosis refers to disease caused by the dimorphic fungusBlastomyces dermatitidis.This infection occurs most often in persons living in midwestern, southeastern, and south central United States and the Canadian provinces that border the Great Lakes and the St. Lawrence Seaway. Recent reports have shown an increase in the incidence of blastomycosis in some of these regions. 

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*Every 12 to 18 months following publication, IDSA reviews its guidelines to determine whether an update is required. This guideline was last reviewed and deemed current as of 04/2013.

Recommendations

Pulmonary Blastomycosis

  1. For moderately severe to severe disease, initial treatment with a lipid formulation of amphotericin B (AmB) at a dosage of 3-5 mg/kg per day or AmB deoxycholate at a dosage of 0.7-1 mg/kg per day for 1-2 weeks or until improvement is noted, followed by oral itraconazole, 200 mg 3 times per day for 3 days and then 200 mg twice per day, for a total of 6-12 months, is recommended (A-III).
  2. For mild to moderate disease, oral itraconazole, 200 mg 3 times per day for 3 days and then once or twice per day for 6-12 months, is recommended (A-II).
  3. Serum levels of itraconazole should be determined after the patient has received this agent for at least 2 weeks, to ensure adequate drug exposure (A-III).

Disseminated Extrapulmonary Blastomycosis

  1. For moderately severe to severe disease, lipid formulation AmB, 3-5 mg/kg per day, or AmB deoxycholate, 0.7-1 mg/kg per day, for 1-2 weeks or until improvement is noted, followed by oral itraconazole, 200 mg 3 times per day for 3 days and then 200 mg twice per day for a total of at least 12 months, is recommended (A-III).
  2. For mild to moderate disease, oral itraconazole, 200 mg 3 times per day for 3 days and then once or twice per day for 6-12 months, is recommended (A-II).
  3. Patients with osteoarticular blastomycosis should receive a total of at least 12 months of antifungal therapy (A-III).
  4. Serum levels of itraconazole should be determined after the patient has received this agent for at least 2 weeks, to ensure adequate drug exposure (A-III).

CNS Blastomycosis

  1. AmB, given as a lipid formulation at a dosage of 5 mg/kg per day over 4-6 weeks followed by an oral azole, is recommended. Possible options for azole therapy include fluconazole, 800 mg per day, itraconazole, 200 mg 2 or 3 times per day, or voriconazole, 200-400 mg twice per day, for at least 12 months and until resolution of CSF abnormalities (B-III).

Treatment for Immunosuppressed Patients with Blastomycosis

  1. AmB, given as a lipid formulation, 3-5 mg/kg per day, or AmB deoxycholate, 0.7-1 mg/kg per day, for 1-2 weeks or until improvement is noted, is recommended as initial therapy for patients who are immunosuppressed, including those with AIDS (A-III).
  2. Itraconazole, 200 mg 3 times per day for 3 days and then twice per day, is recommended as step-down therapy after the patient has responded to initial treatment with AmB and should be given to complete a total of at least 12 months of therapy (B-III).
  3. Serum levels of itraconazole should be determined after the patient has received this agent for at least 2 weeks, to ensure adequate drug exposure (A-III).
  4. Lifelong suppressive therapy with oral itraconazole, 200 mg per day, may be required for immunosuppressed patients if immunosuppression cannot be reversed (A-III) and in patients who experience relapse despite appropriate therapy (C-III).

Treatment for Blastomycosis in Pregnant Women and in Children

  1. During pregnancy, lipid formulation AmB, 3-5 mg/kg per day, is recommended (A-III). Azoles should be avoided because of possible teratogenicity (A-III).
  2. If the newborn shows evidence of infection, treatment is recommended with AmB deoxycholate, 1.0 mg/kg per day (A-III).
  3. For children with severe blastomycosis, AmB deoxycholate, 0.7-1.0 mg/kg per day, or lipid formulation AmB, at a dosage of 3-5 mg/kg per day, is recommended for initial therapy, followed by oral itraconazole, 10 mg/kg per day (up to 400 mg per day) as step-down therapy, for a total of 12 months (B-III).
  4. For children with mild to moderate infection, oral itraconazole, at a dosage of 10 mg/kg per day (to a maximum of 400 mg orally per day) for 6-12 months, is recommended (B-III).
  5. Serum levels of itraconazole should be determined after the patient has received this agent for at least 2 weeks, to ensure adequate drug exposure (A-III).

Additional Resources

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