Sandbox carlos

Immunosupression (AIDS, therapy with high dose corticosteroids, receiptients of TNF-alpha, receiptients of an organ transplant)
Diabetes
Preexisting cardiomyopathy
Pregnancy (third trimester)
Filipino or African
Weight loss of > 10%
Intense night sweats persisting longer than 3 weeks
Infiltrates involving more than one-half of one lung or portions of both lungs
Prominent or persistent hilar adenopathy
Anticoccidiodial complement-fixing antibody concentrations in excess of 1:16

For many (if not most) patients, management may rely on periodic reassessment of symptoms and radiographic findings to assure resolution without antifungal treatment.

Preferred regimen: (Amphotericin B 0.6–1 mg/kg PO qd every 7 days THEN 0.8 mg/kg PO every other day OR Liposomal Amphotericin B 3-5 mg/kg IV q24 hrs OR Amphotericin B lipid complex 5 mg/kg IV q24 hrs until clinical improvement) followed by Itraconazole OR Fluconazole for at least 1 year.
Note (1): Some use combination of Amphotericin B and Fluconazole for progressive severe disease; controlled series lacking.
Note (2): Consultation with specialist recommendation, surgery may be required.

Preferred regimen: Fluconazole 400–1,000 mg PO q24h indefinitely.
Alternative regimen: Amphotericin B 3-5 mg/kg IV q24 hrs PLUS 0.1–0.3 mg qd intrathecal (intraventricular) via reservoir device OR Itraconazole 400–800 mg q24h OR Voriconazole
Note: Some use combination of Amphotericin B and Fluconazole for progressive severe disease; controlled series lacking.

Preferred regimen: Fluconazole PO (Pediatric dose not established, 6 mg per kg q24h used)
Alternative regimen: Amphotericin B 3-5 mg/kg IV q24 hrs PLUS 0.1–0.3 mg daily intrathecal (intraventricular) via reservoir device OR itra 400–800 mg q24h OR Voriconazole

Preferred regimen: Fluconazole 400 mg PO daily OR Itraconazole 200 mg PO bid
Alternative regimen (unresponsive to Fluconazole or Itraconazole): Posaconazole 200 mg PO bid OR Voriconazole 200 mg PO bid
Note: Itraconazole, posaconazole, and voriconazole may have significant interactions with certain antiretro viral agents. These interactions are complex and can be bi-directional

3.2 Severe, non-meningeal infection (diffuse pulmonary infection or severely ill patients with extrathoracic, disseminated disease)

3.2.1 Preferred regimen: Amphotericin B deoxycholate 0.7–1.0 mg/kg IV q12hrs OR Lipid formulation Amphotericin B 4–6 mg/kg IV q24hrs. Duration of therapy: continue until clinical improvement, then switch to an azole.
3.2.2 Alternative regimen: Some specialists will add a triazole (Fluconazole or Itraconazole, with Itraconazole (preferred for bone disease) 400 mg per day to Amphotericin B therapy and continue triazole once Amphotericin B is stopped
Note (1): Therapeutic drug monitoring and dosage adjustment may be necessary to ensure triazole antifungal and antiretroviral efficacy and reduce concentration-related toxicities.
Note (2): Therapy should be continued indefinitely in patients with diffuse pulmonary or disseminated diseases because relapse can occur in 25%–33% of HIV-negative patients. It can also occur in HIV-infected patients with CD4 counts >250 cells/μL

Preferred regimen: Fluconazole 400–800 mg IV or PO daily
Alternative regimen: Itraconazole 200 mg PO tid for 3 days THEN 200 mg PO bid OR Posaconazole 200 mg PO bid OR Voriconazole 200–400 mg PO bid OR Intrathecal Amphotericin B deoxycholate when triazole antifungals are ineffective.
Note (1): Intrathecal amphotericin B should only be given in consultation with a specialist and administered by an individual with experience with the technique.
Note (2): Some patients with meningitis may develop hydrocephalus and require CSF shunting
Note (3): Therapy should be lifelong in patients with meningeal infections because relapse occurs in 80% of HIV-infected patients after discontinuation of triazole therapy

Preferred regimen: Fluconazole 400 mg PO daily (AII), or Itraconazole 200 mg PO BID
Alternative regimen: Posaconazole 200 mg PO BID or Voriconazole 200 mg PO BID

References