Coccidioidomycosis and Valley Fever Guidelines

Updated: Dec 16, 2022
  • Author: George R Thompson III, MD, FIDSA, FECMM; Chief Editor: Michael Stuart Bronze, MD  more...
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IDSA Guidelines on the Treatment of Coccidioidomycosis

Guidelines on coccidioidomycosis by the Infectious Diseases Society of America and the European Confederation of Medical Mycology in cooperation with the International Society for Human and Animal Mycology include the following:{13

  • The IDSA recommends antifungal treatment in patients who, at the time of diagnosis, have significantly debilitating illness.
  • If treatment is begun in nonpregnant adults, the treatment should be an orally absorbed azole antifungal (eg, fluconazole) at a daily dose of 400 mg or more.
  • Patients with symptomatic chronic cavitary coccidioidal pneumonia should be treated with an oral agent such as fluconazole or itraconazole.
  • When surgical management of cavitary coccidioidal pneumonia is undertaken, a video-assisted thoracoscopic surgery (VATS) approach should be attempted.
  • For patients with ruptured coccidioidal cavities, oral azole therapy is recommended. For patients who cannot tolerate oral azole therapy or patients whose disease requires 2 or more surgical procedures for control, intravenous amphotericin B (AmB) is recommended.
  • Azole therapy is recommended for bone and joint coccidioidomycosis.
  • Fluconazole 400-1200 mg orally daily is recommended as initial therapy for most patients with normal renal function. There is no role for a dose of below 400 mg daily in adult patients without substantial renal impairment. Some experts prefer to use itraconazole 200 mg 2-4 times daily, but this requires closer monitoring to ensure adequate absorption, and there are more drug-drug interactions than with fluconazole.
  • Lifelong azole treatment is recommended.
  • The development of symptomatic coccidioidomycosis during pregnancy should prompt consideration of starting antifungal therapy.
  • For women who develop coccidioidomycosis during the first trimester of pregnancy, intrathecal AmB is recommended. After the first trimester and in cases in which disease is diagnosed after the first trimester, an azole antifungal, such as fluconazole or itraconazole, can be prescribed.
  • Empiric therapy with fluconazole at 6-12 mg/kg daily is recommended for infants suspected of having coccidioidomycosis and should be continued until the diagnosis has been ruled out.
  • Breastfeeding is not recommended among mothers on azole antifungals other than fluconazole.