Indication	First Choice	Alternative	Comments/Special Issues
Primary Prophylaxis	N/A	N/A	Primary prophylaxis not routinely indicated in children.
Secondary Prophylaxis	Fluconazole 6 mg/kg body weight (maximum 400 mg) by mouth once daily	Itraconazole 2–5 mg/kg body weight (maximum 200 mg) by mouth per dose twice daily	Lifelong secondary prophylaxis with fluconazole for patients with meningitis or disseminated disease in the immunocompromised patient is recommended. Secondary prophylaxis should be considered after treatment of milder disease if CD4 count remains <250 cells/mm3 or CD4 percentage <15%.
Treatment	Severe Illness with Respiratory Compromise due to Diffuse Pulmonary or Disseminated Non-Meningitic Disease: Amphotericin B deoxycholate 0.5–1.0 mg/kg body weight IV once daily, until clinical improvement. A lipid amphotericin B preparation can be substituted at a dose of 5 mg/kg body weight IV once daily (dosage of the lipid preparation can be increased to as much as 10 mg/kg body weight IV once daily for life-threatening infection). After the patient is stabilized, therapy with an azole (fluconazole or itraconazole) can be substituted and continued to complete a 1-year course of antifungal therapy.	Severe Illness with Respiratory Compromise Due to Diffuse Pulmonary or Disseminated Non-Meningitic Disease (If Unable to Use Amphotericin): Fluconazole 12mg/kg body weight (maximum 800 mg) per dose IV or by mouth once daily Treatment is continued for total of 1 year, followed by secondary prophylaxis.	Surgical debridement of bone, joint, and/or excision of cavitary lung lesions may be helpful. Itraconazole is the preferred azole for treatment of bone infections. Some experts initiate an azole during amphotericin B therapy; others defer initiation of the azole until after amphotericin B is stopped. For treatment failure, can consider voriconazole, caspofungin, or posaconazole (or combinations). However, experience is limited and definitive pediatric dosages have not been determined. Options should be discussed with an expert in the treatment of coccidioidomycosis. Chronic suppressive therapy (secondary prophylaxis) with fluconazole or itraconazole is routinely recommended following initial induction therapy for disseminated disease and is continued lifelong for meningeal disease. Therapy with amphotericin results In a more rapid clinical response in severe, non-meningeal disease.
	Meningeal Infection: Fluconazole 12 mg/kg body weight (maximum 800 mg) IV or by mouth once daily followed by secondary lifelong prophylaxis.	Meningeal Infection (Unresponsive to Fluconazole): IV amphotericin B plus intrathecal amphotericin B followed by secondary prophylaxis. Note: Expert consultation recommended.
	Mild-to-Moderate Non-Meningeal Infection (e.g., Focal Pneumonia): Fluconazole 6–12 mg/kg body weight (maximum 400 mg) per dose IV or by mouth once daily.	Mild-to-Moderate Non-Meningeal Infection (e.g., Focal Pneumonia): Itraconazole 2–5 mg/kg body weight per dose (maximum dose 200 mg) per dose IV or by mouth 3 times daily for 3 days, then 2–5 mg/kg body weight (maximum dose 200 mg) by mouth per dose twice daily thereafter. Duration of treatment determined by rate of clinical response.

Key to Abbreviations: CD4 = CD4 T lymphocyte; IV = intravenous