TABLE 10.

IDSA guidelines for the treatment of osteoarticular mycoses^a

Pathogen(s)	Antifungal agent	Duration	Description
Candida spp.	Fluconazole	Septic arthritis, 6 wks; osteomyelitis, 6–12 mo	The choice of antifungal agent should be guided by susceptibility testing
	Echinocandin (caspofungin, micafungin, or anidulafungin) for at least 2 wks followed by fluconazole or
	Liposomal AmB for at least 2 wks followed by fluconazole
Aspergillus spp.	Primary, voriconazole	No fewer than 8 wks to >6 mo	Guidelines recommend following the same treatment protocols as the ones for invasive pulmonary aspergillosis, but note that there is little experience with echinocandins for the treatment of Aspergillus OA infection
	Alternative, liposomal AmB
	Salvage, ABLC, caspofungin, micafungin, posaconazole, itraconazole
Blastomyces dermatitidis	Mild-to-moderate disease, itraconazole	At least 12 mo
	Severe disease, liposomal AmB for 2 wks followed by itraconazole
Coccidioides immitis	Mild-to-moderate disease, fluconazole or itraconazole	3 yrs to indefinite
	Severe disease, liposomal AmB for 3 mo followed by fluconazole or itraconazole
Cryptococcus neoformans	Fluconazole for patients without cryptococcemia and with a single site of infection and no immunosuppressive risk factors	Maintenance therapy of fluconazole for 6–12 mo; depending on the immune status, patients may require long-term secondary prophylaxis with fluconazole	Osteoarticular infections are not specifically addressed in current IDSA guidelines; recommendations for extrapulmonary non-CNS cryptococcosis in immunocompetent patients are to follow the treatment protocol for CNS disease listed here (see the guidelines for separate recommendations for HIV-positive patients and transplant recipients)
	Otherwise, (i) induction with AmB plus flucytosine for 4 wks, AmB for 6 wks; liposomal AmB or ABLC combined with flucytosine, if possible, for 4 wks; or AmB plus flucytosine for 2 wks (for patients at low risk for therapeutic failure [see guidelines]) or (ii) consolidation therapy with fluconazole (400–800 mg/day) for 8 wks
Histoplasma capsulatum	Mild-to-moderate disease, itraconazole	At least 12 mo	Histoplasma osteoarticular infections usually occur in the setting of disseminated disease
	Severe disease, liposomal AmB for 2–6 wks followed by itraconazole
Sporothrix schenckii	Preferred, itraconazole	At least 12 mo	Alternative, liposomal AmB with a change to itraconazole after a favorable response is achieved

^aRefer to IDSA guidelines for dosing recommendations. Abbreviations: ABLC, amphotericin B lipid complex; AmB, amphotericin B.