Routine use of antifungal medications for primary prophylaxis of coccidioidal infections in children is not recommended (BIII).
Diffuse pulmonary or disseminated infection (not involving the central nervous system) should be treated initially with amphotericin B (AII*). After completion of amphotericin B, treatment with fluconazole or itraconazole should begin (BIII). Alternatively, some experts initiate therapy with amphotericin B combined with a triazole, such as fluconazole, in patients with disseminated disease and continue the triazole after amphotericin B is stopped (BIII).
There is no evidence that lipid preparations of amphotericin are more effective than amphotericin B deoxycholate for the treatment of coccidioidomycosis. Lipid preparations are often preferred because they are better tolerated and associated with less nephrotoxicity than amphotericin B deoxycholate (AII*).
For patients with mild disease (e.g., focal pneumonia), monotherapy with fluconazole or itraconazole is appropriate (BII*).
Itraconazole is preferred for treatment of skeletal infections (AII*).
Because absorption of itraconazole varies from patient to patient, serum concentrations should be measured to ensure effective, non-toxic levels of drug, monitor drug levels following changes in dosage, and assess compliance (BIII).
Amphotericin B preparations are not the drugs of choice for treating coccidioidal meningitis; fluconazole is the preferred drug for treating coccidioidal meningitis (AII*).
Lifelong antifungal suppression (secondary prophylaxis) with either fluconazole or itraconazole is recommended for treating HIV-infected children after disseminated, diffuse pulmonary, and/or meningeal coccidioidomycosis (AII*), even if immune reconstitution is achieved with combination antiretroviral therapy (cART). Lifelong secondary prophylaxis should be considered for children with mild disease and CD4 T lymphocyte cell count <250 cells/mm3 or <15%, even if immune reconstitution is achieved with cART (BIII)
