Table 2.
Summary of Infectious Diseases Society of America guidelines for the treatment of fungal osteoarticular infections
| Category | Treatment | Comments |
|---|---|---|
| Cryptococcus neoformans | Osteoarticular infections are not specifically addressed in current IDSA guidelinesRecommendations for extrapulmonary non-CNS cryptococcosis in immunocompetent patients: follow treatment protocol for CNS disease (see guidelines for separate recommendations for HIV-positive patients and for transplant recipients)Induction therapy:1. AmB plus flucytosine for 4 wk.2. AmB for 6 wk.3. Liposomal AmB or ABLC combined with flucytosine, if possible, for 4 wk.; or4. AmB plus flucytosine for 2 wk. (for patients at low risk for therapeutic failure; see guidelines)Consolidation therapy: fluconazole (400–800 mg/d) for 8 wk.Maintenance therapy: fluconazole (200 mg/d) for 6–12 moPatients without cryptococcemia and with a single site of infection and no immunosuppressive risk factors:Fluconazole for 6–12 moDepending on immune status, patients may require long-term secondary prophylaxis with fluconazole | |
| Candida sp | Fluconazole, or Echinocandin (caspofungin, micafungin, or anidulafungin) for at least 2 wk. followed by fluconazole, or Liposomal AmB for at least 2 wk. followed by fluconazole | Choice of antifungal agent should be guided by susceptibility testingDuration of treatment:Septic arthritis: 6 wk.Osteomyelitis: 6–12 mo for osteomyelitis |
| Aspergillus sp | Primary: voriconazoleAlternative: liposomal AmBSalvage:ABLCCaspofunginMicafunginPosaconazoleItraconazole | Duration: minimum of 8 wk., to > 6 mo Guidelines recommend following same treatment protocols described for invasive pulmonary aspergillosis, but note that there is little experience with echinocandins in the treatment of aspergillus OAI |
| C immitis | Mild-moderate disease: fluconazole or itraconazole Severe disease: liposomal AmB for 3 mo followed by fluconazole or itraconazole | Duration of therapy: 3 y to lifelong |
| Histoplasma capsulatum | Mild-moderate disease: itraconazole Severe disease: liposomal AmB for 2–6 wk., followed by itraconazole | Histoplasma osteoarticular infections usually occur in the setting of disseminated disease. Duration of therapy for disseminated disease: at least 12 mo |
| B dermatitidis | Mild-moderate disease: itraconazole Severe disease: liposomal AmB for 2 wk. followed by itraconazole | Recommended duration of therapy for osteoarticular disease: at least 12 mo |
| Sporothrix schenckii | Preferred: itraconazole Alternative: liposomal AmB with change to itraconazole after a favorable response is achieved | Recommended duration of therapy for osteoarticular disease: at least 12 mo |