Histoplasmosis treatment

Unlabeled Uses Suppression of histoplasmosis treatment of disseminated sporotrichosis, fungal pneumonia and septicemia, or ringworm of the hand... 

Recommended therapy for the treatment of histoplasmosis is summarized in Table 38-1. 

Histoplasmosis (capsules and injection) Treatment of histoplasmosis, including chronic cavitary pulmonary disease and disseminated, nonmeningeal histoplasmosis in nonimmunocompromised or immunocompromised patients. 

For the treatment of blastomycosis, histoplasmosis, and aspergillosis, itraconazole can be given as oral capsules or IV. The safety and efficacy of the injection administered for more than 14 days are not known. 

The spectrum of respiratory tract infections (RTI) can vary from the common cold to acute or chronic bronchitis to community-acquired pneumonia to nosocomial pneumonia and aspiration pneumonia to ventilator-associated pneumonia to chronic pneumonia (in cystic fibrosis, histoplasmosis, tuberculosis, etc.). Important complications are lung abscess and pleural empyema that will often need drainage and prolonged antimicrobial treatment (>6 weeks). 

Initial treatment for histoplasmosis is amphotericin B for moderate-to-severe cases, and oral itraconazole for mild cases. Maintenance therapy is then... 

Itraconazole is most useful in the long-term suppressive treatment of disseminated histoplasmosis in AIDS and in the oral treatment of nonmeningeal, non-life-threatening blastomycosis. It appears to be the drug of choice for all forms of sporotrichosis except meningitis and may have a lower relapse rate in the treatment of disseminated coccidioidomycosis than does fluconazole. 

Blastomycosis, histoplasmosis, sporotrichosis, paracoccidioidomycosis, and chromomycosis are better treated with itraconazole than ketoconazole, although ketoconazole remains an alternative agent. Ketoconazole is ineffective in the treatment of cryptococcosis, aspergillosis, and mucormycosis. Candidemia is best treated with fluconazole or amphotericin B. 

The spectrum of action of azole medications is broad, including many Candida species, C neofbrmans, the endemic mycoses (blastomycosis, coccidioidomycosis, histoplasmosis), the dermatophytes, and, in the case of itraconazole and voriconazole, even aspergillus infections. They are also useful in the treatment of intrinsically amphotericin-resistant organisms such as P boydii. 

Indications Treatment of the following systemic fungal infections Candidiasis Chronic mucocutaneous candidiasis Oral thrush Candiduria Blastomycosis Coccidioidomycosis Histoplasmosis Chromomycosis Paracoccidioidomycosis... 

Antifungal spectrum It is the drug of choice for Cryptococcus neoformans. for candidemia, and for coccidioidomycosis. Fluconazole has also been shown to be useful in the treatment of blastomycosis, candidiasis, and histoplasmosis. These infections are characterized by a high rate of relapse, and fluconazole has proved effective in chronic ambulatory treatment. 

Itraconazole [it ra KON a zole] is a recent addition to the azole family of antifungal agents. Like fluconazole it is a synthetic triazole, and it also lacks the endocrinologic side effects of ketoconazole. Its mode of action is the same as that of the other azoles. Itraconazole is now the drug of choice for the treatment of blastomycosis. Unlike ketoconazole, it is effective in AIDS-associated histoplasmosis. However, current studies show that it may also be effective in the treatment of aspergillosis, candidemia, coccidioidomycosis, and cryptococcosis. Thus it has a broad antifungal spectrum. 

Impaired cell-mediated immunity leaves the host prey to many (opportunistic) infections including candidiasis, coccidioidomycosis, cryptosporidiosis, cytomegalovirus disease, herpes simplex, histoplasmosis, Pneumocystis carinii pneumonia, toxoplasmosis and tuberculosis (with multiply-resistant organisms). Treatment of these conditions is referred to elsewhere in this text for a comprehensive review of the antinticrobial prophylaxis of opportunistic infections in patients with HIV infection, readers are referred to Kovacs Masur 2000 New England Journal of Medicine 342 1416. 

In a review of 10 cases of histoplasmosis in patients treated with infliximab (n = 9) or etanercept n — 1) the infection occurred within 1 week to 6 months after the first dose (57). Of these 10 patients, nine required treatment in an intensive care unit and one died. All lived in regions in which histoplasmosis was endemic. It was not possible to determine which patients had new infections or reactivation of previous infections. 

Nakelchik M, Mangino JE. Reactivation of histoplasmosis after treatment with infliximab. Am J Med 2002 112(1) 78. 

Chronic pulmonary histoplasmosis 0.05 Antifungal therapy generally recommended for all patients to halt further lung destruction and reduce mortality Mild-moderate disease Itraconazole 200 00 mg PO daily x 6-24 months is the treatment of choice Itraconazole and ketoconazole (200-800 mgfday orally for 1 year) are effective in 74% to 86% of cases, but relapses are common fluconazole 200-400 mg daily is less effective (64%) than ketoconazole or itraconazole, and relapses are seen in 29% of responders Severe cf/sease Amphotericin B 0.7 mg/kg/day for a minimum total dose of 35 mj kg is effective in 59% to 100% of cases and should be used in patients who require hospitalization or are unable to take itraconazole due to drug interactions, allergies, failure to absorb drug, or failure to improve clinically after a minimum of 12 weeks of itraconazole therapy... 

In regions experiencing high rates of histoplasmosis (>5 cases/ 100 patient-years), itraconazole 200 mg/day is recommended as prophylactic therapy in HIV-infected patients. Fluconazole is not an acceptable alternative because of its inferior activity against H. cap-sulatum and its lower efficacy for the treatment of histoplasmosis. ... 

Therapy for coccidioidomycosis is difficult, and the results are unpredictable. Guidelines are available for treatment of this disease however, optimal treatment for many forms of this disease still generates debate. The efficacy of antifungal therapy for coccidioidomycosis is often less certain than that for other fungal etiologies, such as blastomycosis, histoplasmosis, or cryptococcus, even when in vitro susceptibilities and the sites of infections are similar. The refractoriness of coccidioidomycosis may relate to the ability of C. immitis spherules to release hundreds of endospores, maximally challenging host defensesFortunately, only approximately 5% of infected patients require therapy. ... 

Should lipid formulations of amphotericin B be used rather than the traditonal deoxycholate formulation Many clinicians feel that lipid formulations have shown clear superiority in the treatment of aspergillosis and histoplasmosis and are "at least as good" as deoxycholate amphotericin B for the treatment of Candida, cryptococcosis, and febrile neutropenia. However, they lack FDA approval for these infections except (in some cases) as salvage therapy. ... 

---