| Fungal pathogen |
Indication for
antifungal therapy |
Surgical care and
other treatments |
Antifungal drugs used |
| Histoplasmosis |
Acute pulmonary
histoplasmosis with hypoxia; prolonged moderate symptoms
more than 1 month; disseminated disease;
immunosuppressed host
Mortality for untreated
disseminated disease 80%; reduced to 25% with treatment |
Significant hemoptysis;
recurrent pneumonia; repair of bronchopleural fistula
Corticosteroids in
severe hypoxia
Anti-inflammatory
agents to treat rheumatologic syndromes |
Amphotericin B induces
rapid response in patients who are severely ill
Azoles/triazoles in
patients with milder illness |
| Coccidioidomycosis |
Disseminated disease;
chronic pulmonary disease; acute pulmonary infection
with hypoxia or protracted morbidity (more than 1-2 mo);
immunosuppressed host (worst outcome, 70% mortality) |
Surgical debridement
or resection of infective tissue often necessary adjunct
to antifungal treatment
Anti-inflammatory
agents for rheumatologic syndromes |
Amphotericin B
effective in more than 90% of cases
Fluconazole or
itraconazole after improvement
Treatment less
effective than in other endemic mycoses |
| Blastomycosis |
Persistent or
recurrent symptoms of acute or chronic pulmonary disease
or with pleural involvement; disseminated disease |
|
Amphotericin B
response rates of 77-90%
Itraconazole successful
in 90%
Ketoconazole response
of 80%; poor outcome in patients who are
immunosuppressed
Fluconazole less
effective, 65% response rate
Chronic maintenance
treatment essential for all patients with AIDS or
meningitis |
| Cryptococcosis |
Patients who
immunosuppressed and symptomatic; patients who are
immunocompetent with disease progression; any patients
with meningitis or disseminated disease |
|
Amphotericin B in
patients who are severely ill
Fluconazole in milder
cases or after clinical response to amphotericin B
Lifelong maintenance
therapy in AIDS due to frequent recurrences when
treatment is stopped |
| Aspergillosis;
mucormycoses |
All patients with
invasive disease; in patients who are immunosuppressed,
early diagnosis and empiric treatment for persistent
fever not responding to broad-spectrum antibiotics; high
mortality once infiltrates and symptoms appear;
prognosis ultimately linked to severity and outcome of
underlying disease
Mortality of 50-60% in
patients with AIDS; mortality as high as 85% in patients
with prior bone marrow transplantation |
Aggressive surgical
debridement of necrotic tissue important in mucormycosis,
especially if confined to lungs
Rapid tapering of
immunosuppressive agents and corticosteroids and
reversal of neutropenia (if possible) |
Amphotericin B often
started empirically in patients who are neutropenic with
fever and unexplained pulmonary infiltrates who cannot
tolerate an invasive pulmonary procedure
Flucytosine with
amphotericin B synergistic in animal models
Rifampicin often added
empirically when patient is deteriorating in face of
amphotericin B
Itraconazole used to
complete treatment with initial response to amphotericin
B; Mucor species generally resistant to azoles
Ketoconazole may be
antagonistic with amphotericin B |
| Candidiasis |
All patients with
invasive disease or dissemination; important to reverse
factors affecting immune status |
Rapid tapering of
immunosuppressive agents and corticosteroids; important
to remove indwelling infected intravenous lines or
urinary catheters in setting of hematogenous spread |
Amphotericin B
mainstay
Flucytosine may be of
benefit when added to amphotericin B
Fluconazole use in
pulmonary disease not studied but is effective in
hepatosplenic candidiasis and candidemia |
